N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.24 - Rules relating to coverage for the diagnosis and treatment of alcoholism and alcohol abuse in group (including group remittance policies issued by article 43 corporations) and school blanket health insurance policies

In accordance with sections 3221(l)(6)-(7) and 4303(k)-(l) of the Insurance Law, the following rules shall apply:

(a) Definitions.
(1) For the purposes of this section and sections 3221(l)(6)-(7) and 4303(k)-(l) of the Insurance Law, the following definition shall apply:
(i) Coverage for inpatient hospital care, as referred to in the aforementioned sections of the Insurance Law, means reimbursement for hospitalization on an expense-incurred basis.
(2) For the purposes of this section and sections 3221(l) and 4303(l) of the Insurance Law, the following definitions shall apply:
(i) Family members means those who are covered family members under the insurance policy covering the person receiving or in need of treatment for alcoholism or alcohol abuse.
(ii) Visits means the rendering of diagnostic, medical or therapeutic services, including comprehensive visits, day visits or clinic visits as defined in Part 330 of Title 14 of the Official Compilation of Codes, Rules and Regulations (regulations of the Division of Alcoholism and Alcohol Abuse governing outpatient facilities). Visits do not include socialization visits.
(b) Benefits.
(1) The level of benefits must be consistent with the level of benefits for other diseases covered under the policy.
(i) A maximum dollar payment may not be applicable to coverage for the diagnosis and treatment of alcoholism and alcohol abuse unless a similar limitation is applicable to other diseases covered under the policy.
(ii) Annual deductibles and coinsurance amounts must be consistent with those imposed on benefits for other diseases covered under the policy.
(2) Proposals by insurers to substitute inpatient days of coverage not otherwise available under the policy for the diagnosis and treatment of alcoholism and alcohol abuse, for outpatient visits for the diagnosis and treatment of alcoholism and alcohol abuse will be reviewed by the superintendent to determine if the proposal complies with the intent of sections 3221(l)(7) and 4303(l) of the Insurance Law. In no event may the number of covered outpatient visits in any calendar year be less than 30.
(3) Coverage must include up to 20 outpatient visits for family members, even if the covered person in need of treatment has not received or is not receiving treatment for alcoholism or alcohol abuse, provided that the total number of such visits, when combined with those of the covered person in need of treatment, need not exceed 60 outpatient visits in any calendar year, and provided further that the 60 visits shall be reduced only by the number of visits actually utilized by the family members. Coverage for family members must include visits for remediation, through counseling and education, of the adverse effects on the physical and mental health of family members resulting from a close relationship with the covered person receiving or in need of treatment for alcoholism or alcohol abuse.
(4) Coverage may be limited to one outpatient visit per day.
(5) Major medical insurance need not duplicate the mandated benefits for alcoholism and alcohol abuse payable under the insured's group or blanket hospital insurance.
(6) Coverage may be limited to facilities in New York State which are certified by the Division of Alcoholism and Alcohol Abuse and, in other states, to those which are accredited by the Joint Commission on Accreditation of Hospitals as alcoholism treatment programs. Coverage must be provided for services rendered in and billed by these facilities, even if the services were rendered by a provider who would not otherwise be reimbursed under the policy. Coverage must be provided for services rendered in and billed by these facilities, notwithstanding the permissible exclusion for treatment in a government hospital set forth in section 52.16(c)(8) of this Part, unless no charge would have been made in the absence of insurance.
(7) Insurers may require a facility to submit a treatment plan within no less than 10 days from the date of the first visit. Insurers may also require that such a treatment plan be approved by the insurer as a condition of continued coverage.
(8) Insurers may enter into participation arrangements whereby participating providers are reimbursed at different levels than nonparticipating providers. Deductibles and coinsurance amounts for services provided by nonparticipating providers must be consistent with those applicable to other services provided by nonparticipating providers under the insurance contract.
(9) Policies providing indemnity-type benefits and disability income benefits are not policies that provide coverage for inpatient hospital care and are therefore not subject to sections 3221(l)(6)-(7) and 4303(k)-(l) of the Insurance Law and this section.
(10) Policies providing coverage for accidents only are not subject to sections 3221(l)(6)-(7) and 4303(k)-(l) of the Insurance Law and this section.
(c) Report to the superintendent. In accordance with sections 3221(l)(6) and 4303(k) of the Insurance Law, the following rules shall apply:
(1) The report must be furnished to the superintendent by all commercial insurers, article 43 corporations and HMO's. Such report should be sent to the Superintendent of Insurance, One Commerce Plaza, Albany, NY 12257.
(2) The following information should be contained in the report:
(i) the number of insured groups situated in this State that have purchased the inpatient chemical dependence coverage set forth in sections 3221(l)(6) and 4303(k) of the Insurance Law;
(ii) the number of insured groups situated in this State that have a level of inpatient chemical dependence coverage higher than as set forth in sections 3221(l)(6) and 4303(k) of the Insurance Law;
(iii) the number of persons covered under subparagraph (i) of this paragraph;
(iv) the number of persons covered under subparagraph (ii) of this paragraph; and
(v) the type of insurance, as defined in sections 52.5 through 52.11 of this Part, that includes the inpatient chemical dependence coverage.
(3) Time periods.
(i) reports should cover each calendar year and provide the information requested in paragraph (2) of this subdivision for:
(a) inpatient chemical dependence coverage issued during that year; and
(b) all inpatient chemical dependence coverage currently in force;
(ii) each report is due on March 1st of the next succeeding calendar year.

Notes

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.24

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