Insurance Circular Letter No. 14 (2019)

December 20, 2019

STATUTORY AND REGULATORY REFERENCES: N.Y. Ins. Law §§ 3201, 3216, 3217-a, 3221, 4303, 4324, and Article 49; N.Y. Pub. Health Law Articles 44 and 49; 14 NYCRR Part 822

I. Purpose

This circular letter provides direction to insurers authorized to write accident and health insurance in this state, article 43 corporations, HMOs, student health plans certified pursuant to Insurance Law § 1124, and municipal cooperative health benefit plans (collectively, “issuers”) regarding coverage for peer support services that are provided as part of a substance use disorder outpatient program.

II. Discussion

Insurance Law §§ 3216(i)(31), 3221(l)(7), and 4303(l) require every policy or contract that provides medical, major medical, or similar comprehensive-type coverage to provide outpatient coverage for the diagnosis and treatment of substance use disorder, including detoxification and rehabilitation services. Under these sections, coverage may be limited to facilities in New York State that are licensed, certified, or otherwise authorized by the Office of Addiction Services and Supports (“OASAS”) to provide outpatient substance use disorder services and, in other states, to those facilities that are accredited by the Joint Commission as alcoholism or chemical dependence substance abuse treatment programs and are similarly licensed, certified, or otherwise authorized in the state in which the facility is located.

Questions have arisen as to whether issuers must cover peer support services for the treatment of substance use disorder when medically necessary and provided as part of an outpatient substance use disorder treatment program by a facility that is licensed, certified, or otherwise authorized by OASAS to provide outpatient substance use disorder services. A peer support service is defined in 14 NYCRR § 822.5(aa) as “a face to face service provided by a peer advocate as defined in Part 800 of this Title. Peer support services are services for the purpose of outreach for engaging an individual to consider entering treatment, reinforcing current patients’ engagement in treatment, and connecting patients to community-based recovery supports consistent with treatment/recovery and discharge plans.”

Because the Insurance Law requires coverage of outpatient substance use disorder treatment in facilities that are licensed, certified or otherwise authorized by OASAS, and facilities that are licensed, certified or otherwise authorized by OASAS as outpatient substance use disorder programs provide peer support services as part of an outpatient substance use disorder program, an issuer may not deny coverage of medically necessary peer support services as a non-covered benefit when provided by such facility as part of an outpatient substance use disorder program if all of the other terms and conditions of the policy or contract are met.

III. Conclusion

An issuer may not deny as a non-covered benefit medically necessary peer support services provided as part of an outpatient substance use disorder program by a facility licensed, certified, or otherwise authorized by OASAS to provide outpatient substance use disorder services if all the other terms and conditions of the policy or contract are met.

Please direct any questions regarding this circular letter to Thomas Fusco, Supervising Insurance Attorney, by mail at Health Bureau, New York State Department of Financial Services, Walter J. Mahoney Office Building, 65 Court Street, Room 7, Buffalo, New York 14202 or by e-mail at [email protected].

Very truly yours,

Lisette Johnson
Chief, Health Bureau