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Bill No.: Summary Actions Committee&nbspVotes Floor&nbspVotes Memo Text LFIN Chamber&nbspVideo/Transcript S04867 Summary: BILL NO S04867A &nbsp SAME AS SAME AS A07522-A

&nbsp SPONSOR FAHY &nbsp COSPNSR FERNANDEZ, JACKSON, ROLISON, WEBB &nbsp MLTSPNSR &nbsp Amd §§3216, 3221 & 4303, Ins L &nbsp Prohibits the application of fail-first or step therapy protocols to coverage for the diagnosis and treatment of serious mental health conditions; defines serious mental health condition.

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STATE OF NEW YORK ________________________________________________________________________

4867--A Cal. No. 583

2025-2026 Regular Sessions

IN SENATE

February 13, 2025 ___________

Introduced by Sens. FAHY, JACKSON, WEBB -- read twice and ordered print- ed, and when printed to be committed to the Committee on Insurance -- reported favorably from said committee, ordered to first and second report, ordered to a third reading, amended and ordered reprinted, retaining its place in the order of third reading

AN ACT to amend the insurance law, in relation to prohibiting the appli- cation of fail-first or step therapy protocols to coverage for the diagnosis and treatment of serious mental health conditions

The People of the State of New York, represented in Senate and Assem- bly, do enact as follows:

1 Section 1. Item (ii) of subparagraph (A) and subparagraphs (C) and (E) 2 of paragraph 35 of subsection (i) of section 3216 of the insurance law, 3 item (ii) of subparagraph (A) as amended by chapter 62 of the laws of 4 2023 and subparagraphs (C) and (E) as added by section 8 of subpart A of 5 part BB of chapter 57 of the laws of 2019, are amended to read as 6 follows: 7 (ii) where the policy provides coverage for physician services, such 8 policy shall include benefits for outpatient care provided by a psychia- 9 trist or psychologist licensed to practice in this state, a licensed 10 clinical social worker within the lawful scope of [ his or her ] their 11 practice, who is licensed pursuant to article one hundred fifty-four of 12 the education law, a mental health counselor, marriage and family thera- 13 pist, or psychoanalyst licensed pursuant to article one hundred sixty- 14 three of the education law, a nurse practitioner licensed to practice in 15 this state, or a professional corporation or university faculty practice 16 corporation thereof , including outpatient drug coverage . Nothing herein 17 shall be construed to modify or expand the scope of practice of a mental 18 health counselor, marriage and family therapist, or psychoanalyst 19 licensed pursuant to article one hundred sixty-three of the education 20 law. Further, nothing herein shall be construed to create a new mandated 21 health benefit.

EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD09475-02-5

S. 4867--A 2

1 (C) Coverage under this paragraph shall not apply financial require- 2 ments or treatment limitations to mental health benefits , including 3 outpatient drug coverage, that are more restrictive than the predominant 4 financial requirements and treatment limitations applied to substantial- 5 ly all medical and surgical benefits covered by the policy . Coverage 6 under this paragraph, including drug coverage, shall not apply any of 7 the following to a drug or drugs prescribed for a serious mental health 8 condition: 9 (i) a fail-first or step therapy protocol, as defined by section four 10 thousand nine hundred of this chapter; or 11 (ii) a prior authorization requirement, as established pursuant to 12 subsection (h) of section four thousand nine hundred three of this chap- 13 ter . 14 (E) For purposes of this paragraph: 15 (i) "financial requirement" means deductible, copayments, coinsurance 16 and out-of-pocket expenses; 17 (ii) "predominant" means that a financial requirement or treatment 18 limitation is the most common or frequent of such type of limit or 19 requirement; 20 (iii) "treatment limitation" means limits on the frequency of treat- 21 ment, number of visits, days of coverage, or other similar limits on the 22 scope or duration of treatment and includes nonquantitative treatment 23 limitations such as: medical management standards limiting or excluding 24 benefits based on medical necessity, or based on whether the treatment 25 is experimental or investigational; formulary design for prescription 26 drugs; network tier design; standards for provider admission to partic- 27 ipate in a network, including reimbursement rates; methods for determin- 28 ing usual, customary, and reasonable charges; fail-first or step therapy 29 protocols; exclusions based on failure to complete a course of treat- 30 ment; and restrictions based on geographic location, facility type, 31 provider specialty, and other criteria that limit the scope or duration 32 of benefits for services provided under the policy; [ and ] 33 (iv) "mental health condition" means any mental health disorder as 34 defined in the most recent edition of the diagnostic and statistical 35 manual of mental disorders or the most recent edition of another gener- 36 ally recognized independent standard of current medical practice such as 37 the international classification of diseases[ . ] ; and 38 (v) "serious mental health condition" means the following mental 39 health disorders as defined in the most recent edition of the diagnostic 40 and statistical manual of mental disorders: 41 (I) neurodevelopmental disorders; 42 (II) schizophrenia spectrum and other psychotic disorders; 43 (III) bipolar and related disorders; 44 (IV) depressive disorders; 45 (V) anxiety disorders; 46 (VI) obsessive-compulsive and related disorders; 47 (VII) trauma-and-stressor-related disorders; 48 (VIII) neurodegenerative disorders; and 49 (IX) substance-related and addictive disorders. 50 § 1-a. Item (v) of subparagraph (E) of paragraph 35 of subsection (i) 51 of section 3216 of the insurance law, as added by section one of this 52 act, is renumbered item (viii). 53 § 2. Item (ii) of subparagraph (A) and subparagraphs (C) and (E) of 54 paragraph 5 of subsection (l) of section 3221 of the insurance law, item 55 (ii) of subparagraph (A) as amended by chapter 62 of the laws of 2023 56 and subparagraphs (C) and (E) as added by section 14 of subpart A of

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1 part BB of chapter 57 of the laws of 2019, are amended to read as 2 follows: 3 (ii) where the policy provides coverage for physician services, it 4 shall include benefits for outpatient care provided by a psychiatrist or 5 psychologist licensed to practice in this state, or a mental health 6 counselor, marriage and family therapist, or psychoanalyst licensed 7 pursuant to article one hundred sixty-three of the education law, or a 8 licensed clinical social worker within the lawful scope of [ his or her ] 9 their practice, who is licensed pursuant to article one hundred fifty- 10 four of the education law, a nurse practitioner licensed to practice in 11 this state, or a professional corporation or university faculty practice 12 corporation thereof , including outpatient drug coverage . Nothing herein 13 shall be construed to modify or expand the scope of practice of a mental 14 health counselor, marriage and family therapist, or psychoanalyst 15 licensed pursuant to article one hundred sixty-three of the education 16 law. Further, nothing herein shall be construed to create a new mandated 17 health benefit. 18 (C) Coverage under this paragraph shall not apply financial require- 19 ments or treatment limitations to mental health benefits , including 20 outpatient drug coverage, that are more restrictive than the predominant 21 financial requirements and treatment limitations applied to substantial- 22 ly all medical and surgical benefits covered by the policy . Coverage 23 under this paragraph, including drug coverage, shall not apply any of 24 the following to a drug or drugs prescribed for a serious mental health 25 condition: 26 (i) a fail-first or step therapy protocol, as defined by section four 27 thousand nine hundred of this chapter; or 28 (ii) a prior authorization requirement, as established pursuant to 29 subsection (h) of section four thousand nine hundred three of this chap- 30 ter . 31 (E) For purposes of this paragraph: 32 (i) "financial requirement" means deductible, copayments, coinsurance 33 and out-of-pocket expenses; 34 (ii) "predominant" means that a financial requirement or treatment 35 limitation is the most common or frequent of such type of limit or 36 requirement; 37 (iii) "treatment limitation" means limits on the frequency of treat- 38 ment, number of visits, days of coverage, or other similar limits on the 39 scope or duration of treatment and includes nonquantitative treatment 40 limitations such as: medical management standards limiting or excluding 41 benefits based on medical necessity, or based on whether the treatment 42 is experimental or investigational; formulary design for prescription 43 drugs; network tier design; standards for provider admission to partic- 44 ipate in a network, including reimbursement rates; methods for determin- 45 ing usual, customary, and reasonable charges; fail-first or step therapy 46 protocols; exclusions based on failure to complete a course of treat- 47 ment; and restrictions based on geographic location, facility type, 48 provider specialty, and other criteria that limit the scope or duration 49 of benefits for services provided under the policy; [ and ] 50 (iv) "mental health condition" means any mental health disorder as 51 defined in the most recent edition of the diagnostic and statistical 52 manual of mental disorders or the most recent edition of another gener- 53 ally recognized independent standard of current medical practice such as 54 the international classification of diseases[ . ] ; and

S. 4867--A 4

1 (v) "serious mental health condition" means the following mental 2 health disorders as defined in the most recent edition of the diagnostic 3 and statistical manual of mental disorders: 4 (I) neurodevelopmental disorders; 5 (II) schizophrenia spectrum and other psychotic disorders; 6 (III) bipolar and related disorders; 7 (IV) depressive disorders; 8 (V) anxiety disorders; 9 (VI) obsessive-compulsive and related disorders; 10 (VII) trauma-and-stressor-related disorders; 11 (VIII) neurodegenerative disorders; and 12 (IX) substance-related and addictive disorders. 13 § 2-a. Item (v) of subparagraph (E) of paragraph 5 of subsection (l) 14 of section 3221 of the insurance law, as added by section two of this 15 act, is renumbered item (viii). 16 § 3. Paragraphs 2, 4 and 6 of subsection (g) of section 4303 of the 17 insurance law, paragraph 2 as amended by chapter 62 of the laws of 2023, 18 and paragraphs 4 and 6 as added by section 23 of subpart A of part BB of 19 chapter 57 of the laws of 2019, are amended to read as follows: 20 (2) where the contract provides coverage for physician services such 21 contract shall provide benefits for outpatient care provided by a 22 psychiatrist or psychologist licensed to practice in this state, or a 23 mental health counselor, marriage and family therapist, or psychoanalyst 24 licensed pursuant to article one hundred sixty-three of the education 25 law, or a licensed clinical social worker within the lawful scope of 26 [ his or her ] their practice, who is licensed pursuant to article one 27 hundred fifty-four of the education law, a nurse practitioner licensed 28 to practice in this state, or professional corporation or university 29 faculty practice corporation thereof , including outpatient drug 30 coverage . Nothing herein shall be construed to modify or expand the 31 scope of practice of a mental health counselor, marriage and family 32 therapist, or psychoanalyst licensed pursuant to article one hundred 33 sixty-three of the education law. Further, nothing herein shall be 34 construed to create a new mandated health benefit. 35 (4) Coverage under this subsection shall not apply financial require- 36 ments or treatment limitations to mental health benefits , including 37 outpatient drug coverage, that are more restrictive than the predominant 38 financial requirements and treatment limitations applied to substantial- 39 ly all medical and surgical benefits covered by the contract . Coverage 40 under this paragraph, including drug coverage, shall not apply any of 41 the following to a drug or drugs prescribed for a serious mental health 42 condition: 43 (i) a fail-first or step therapy protocol, as defined by section four 44 thousand nine hundred of this chapter; or 45 (ii) a prior authorization requirement, as established pursuant to 46 subsection (h) of section four thousand nine hundred three of this chap- 47 ter . 48 (6) For purposes of this subsection: 49 (A) "financial requirement" means deductible, copayments, coinsurance 50 and out-of-pocket expenses; 51 (B) "predominant" means that a financial requirement or treatment 52 limitation is the most common or frequent of such type of limit or 53 requirement; 54 (C) "treatment limitation" means limits on the frequency of treatment, 55 number of visits, days of coverage, or other similar limits on the scope 56 or duration of treatment and includes nonquantitative treatment limita-

S. 4867--A 5

1 tions such as: medical management standards limiting or excluding bene- 2 fits based on medical necessity, or based on whether the treatment is 3 experimental or investigational; formulary design for prescription 4 drugs; network tier design; standards for provider admission to partic- 5 ipate in a network, including reimbursement rates; methods for determin- 6 ing usual, customary, and reasonable charges; fail-first or step therapy 7 protocols; exclusions based on failure to complete a course of treat- 8 ment; and restrictions based on geographic location, facility type, 9 provider specialty, and other criteria that limit the scope or duration 10 of benefits for services provided under the contract; [ and ] 11 (D) "mental health condition" means any mental health disorder as 12 defined in the most recent edition of the diagnostic and statistical 13 manual of mental disorders or the most recent edition of another gener- 14 ally recognized independent standard of current medical practice such as 15 the international classification of diseases[ . ] ; and 16 (E) "serious mental health condition" means the following mental 17 health disorders as defined in the most recent edition of the diagnostic 18 and statistical manual of mental disorders: 19 (I) neurodevelopmental disorders; 20 (II) schizophrenia spectrum and other psychotic disorders; 21 (III) bipolar and related disorders; 22 (IV) depressive disorders; 23 (V) anxiety disorders; 24 (VI) obsessive-compulsive and related disorders; 25 (VII) trauma-and-stressor-related disorders; 26 (VIII) neurodegenerative disorders; and 27 (IX) substance-related and addictive disorders. 28 § 3-a. Subparagraph (E) of paragraph 6 of subsection (g) of section 29 4303 of the insurance law, as added by section three of this act, is 30 relettered subparagraph (H). 31 § 4. This act shall take effect on the first of January next succeed- 32 ing the date on which it shall have become a law and shall apply to all 33 policies and contracts issued, renewed, modified, altered or amended on 34 or after such date; provided however, that sections one-a, two-a and 35 three-a of this act shall take effect on the same date and in the same 36 manner as subpart A of part II of chapter 57 of the laws of 2023 takes 37 effect.

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