New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

George E. Pataki
Governor

Howard Mills
Superintendent

The Office of General Counsel issued the following opinion on April 7, 2005, representing the position of the New York State Insurance Department.

RE: Reimbursement for Services Provided by a Social Worker.

Question Presented:

May ABC Insurer (ABC) refuse to provide reimbursement for services provided by a social worker under a group point of service program because such social worker has been licensed less than six years in New York?

Conclusion:

Pursuant to Section 3221(l)(4), if coverage was requested by the policyholder, ABC must provide coverage for the services of a clinical social worker who is duly licensed pursuant to Article 154 of the Education Law, if the social worker meets the minimum experience requirements set forth therein, regardless of the number of years the social worker has been licensed.

Facts:

The inquirer states that he is attempting to adjudicate claims for an employee with a group point of service plan issued by ABC. The employee has received psychotherapy treatments from a licensed social worker in New York City over the course of the last 11 months. ABC is denying any payment on these services, stating that since the social worker has been licensed in New York for less than six years, legally it does not have to issue reimbursement. ABC would like to know if this is correct.

Analysis:

ABC was converted from an Article 43 non-profit health services corporation to an Article 42 accident and health insurer. Consequently, Article 32 of the Insurance Law applies. N.Y. Ins. Law § 3221(l)(4) (McKinney Supp. 2005) applies to group or blanket accident and health insurance policies and provides, in relevant part, as follows:


(l) (4)(A) Every insurer delivering a group policy or issuing a group policy for delivery, in this state, which provides reimbursement for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in such policy, by physicians, psychiatrists or psychologists, must make available and if requested by the policyholder provide the same coverage to insureds for such services when performed by a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to article one hundred fifty-four of the education law. Written notice of the availability of such coverage shall be delivered to the policyholder prior to inception of such group policy and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.

(B) The state board for social work shall maintain a list of all licensed clinical social workers qualified for reimbursement under this paragraph.

(C) Such coverage shall be made available at the inception of all new policies and, with respect to all other policies at any subsequent annual anniversary date of the policy subject to evidence of insurability.

(D) In addition to the requirements of subparagraph (A) of this paragraph, every insurer issuing a group policy for delivery in this state which policy provides reimbursement to insureds for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in such policy, by physicians, psychiatrists or psychologists, must provide the same coverage to insureds for such services when performed by a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to subdivision two of section seven thousand seven hundred four of the education law and in addition shall have either (i) three1 or more additional years experience in psychotherapy, which for the purposes of this subparagraph shall mean the use of verbal methods in interpersonal relationships with the intent of assisting a person or persons to modify attitudes and behavior which are intellectually, socially or emotionally maladaptive, under supervision, satisfactory to the state board for social work, in a facility, licensed or incorporated by an appropriate governmental department, providing services for diagnosis or treatment of mental, nervous or emotional disorders or ailments, or (ii) three or more additional years experience in psychotherapy under the supervision, satisfactory to the state board for social work, of a psychiatrist, a licensed and registered psychologist or a licensed clinical social worker qualified for reimbursement pursuant to subsection (h) of this section, or (iii) a combination of the experience specified in items (i) and (ii) totaling three years, satisfactory to the state board for social work. The state board for social work shall maintain a list of all licensed clinical social workers qualified for reimbursement under this subparagraph.

Thus, pursuant to Section 3221(l) (4)(A), if a group policy issued by an accident and health insurer provides coverage for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, by physicians, psychiatrists or psychologists, the policy must make available, if requested by the policyholder, the same coverage to insureds for such services when performed by a licensed clinical social worker within the lawful scope of his or her practice, who is licensed pursuant to article one hundred fifty-four of the education law. Pursuant to Section 3221(l)((4)(D), if the social worker meets the experience requirements stated therein, coverage is mandatory, regardless of the number of years the social worker has been licensed.

The inquirer was directed to file a complaint with the Department’s Consumer Services Bureau, which includes specific details and relevant documentations, if the insurer continues to deny coverage.

For further information you may contact Senior Attorney Pascale Jean-Baptiste at the New York City Office.


1  This requirement was recently changed by the Legislature from six years to three years by Ch. 230 of the Laws of 2004.