2
an out-of-network psychiatrist. After intervention from a Helpline advocate, HealthNow agreed to
process claims at the in-network rate. Similarly, through intervention of a Helpline advocate, a Cigna
member was able to get in-patient psychiatric treatment covered by the health plan, after initially
being denied. These are just a few examples of the many resolutions achieved on behalf of New York
healthcare consumers.
A. Background
Timothy’s Law mandates that New York group health plans that provide coverage for inpatient
hospital care or physician services must also provide “broad-based coverage for the diagnosis and
treatment of mental, nervous or emotional disorders or ailments, . . . at least equal to the coverage
provided for other health conditions.” (emphasis added).
1
Further, all group plans must cover, annually,
a minimum of 30 days of inpatient care, 20 visits of outpatient care, and up to 60 visits of partial
hospitalization treatment for the diagnosis and treatment of mental, nervous or emotional disorders
or ailments.
2
Timothy’s Law also requires that deductibles, copayments and co-insurance for mental
health treatment be consistent with those imposed on other benets,
3
and that utilization review for
mental health benets be applied “in a consistent fashion to all services covered by [health insurance
and health maintenance organization] contracts.”
4
Finally, New York law requires health plans to cover
inpatient and outpatient treatment for substance use disorder (“SUD”), and to do so consistent with the
federal Mental Health Parity and Addiction Equity Act (the “Federal Parity Act”).
5
The Federal Parity Act prohibits large group, individual, and Medicaid health plans that
provide both medical/surgical benets and mental health or SUD benets, from: (i) imposing nancial
requirements (such as deductibles, copayments, co-insurance, and out-of-pocket expenses) on mental
health or SUD benets that are more restrictive than the predominant level of nancial requirements
applied to substantially all medical/surgical benets; (ii) imposing treatment limitations (such as
limits on the frequency of treatment, number of visits, and other limits on the scope or duration of
treatment) on mental health or SUD treatment that are more restrictive than the predominant treatment
limitations applied to substantially all medical/surgical benets, or applicable only with respect to
mental health or SUD benets; and (iii) conducting medical necessity review for mental health or
SUD benets using processes, strategies or standards that are not comparable to, or are applied more
stringently than, those applied to medical necessity review for medical/surgical benets.
6
1 N.Y. Ins. Law §§ 3221(l)(5)(A); 4303(g)(1).
2 N.Y. Ins. Law §§ 3221(l)(5)(A)(i)&(ii); 4303(g)(1)(A)&(B).
3 N.Y. Ins. Law §§ 3221(l)(5)(A)(iii); 4303(g)(1)(C).
4 2006 N.Y. Laws Ch. 748, § 1.
5 N.Y. Ins. Law §§ 3221(l)(7)(A); 4303(l)(1); and 3216(i)(31).
6 42 U.S.C. § 300gg-26; 45 C.F.R. § 146.136(c)(4)(i). The essential health benet regulations under the Affordable
Care Act extend the Federal Parity Act’s requirements to small and individual plans. 45 C.F.R. § 156.115(a)(3).