State advises health insurers on requirements to cover substance-abuse treatment

The New York State Department of Financial Services (DFS) has issued guidance to health insurers outlining new insurance-coverage requirements for substance-abuse treatment

Gov. Andrew Cuomo announced the DFS guidance on Oct 19.

The action follows a new state law to combat the heroin and opioid "crisis" in New York, the DFS said in a news release.

The new law requires health insurers to cover medication, including naloxone, for detoxification or maintenance treatment of substance-use disorders under large-group insurance policies.

The new requirement "mirrors" the coverage requirements for individual and smallgroup policies, DFS said.

It also requires health insurers to provide coverage without preauthorization for inpatient substance-abuse treatment in facilities that participate in their networks and are certified by the New York State Office of Alcoholism and Substance Abuse Services.

"Health insurers have an obligation to cover costs for lifesaving substance-abuse treatment and our administration will have zero tolerance for those who seek to sidestep this responsibility," Cuomo said in the DFS release. "This action is an important step toward breaking the cycle of addiction and... ending the epidemic of opioid abuse in New York once and for all."

The new guidance alerts health insurers that they must provide inpatient and outpatient coverage for detoxification and maintenance-treatment medication, including naloxone.

It also instructs health insurers that they must eliminate prior-authorization requirements for a five-day emergency supply of prescribed medications for the treatment of substance-use disorder "when an emergency arises."

The DFS guidance outlines insurer-utilization review requirements, and includes timeframes under which the health insurers must make the utilization-review determinations.

The department will review health insurers' compliance with requirements for coverage during market-conduct exams and will "take action against any insurers found to have failed to meet all statutory and regulatory requirements for coverage of substance use disorder treatment" *