New York invests over $200 million to fight heroin and opioid epidemic

The Lead - 2017

NYS invest millions to fight drug epidemic

New York invests over $200 million to fight heroin and opioid epidemic

Late last year, New York State passed significant legislation to fight the heroin and opioid abuse epidemic. Included are measures to increase life-saving overdose reversal medication; regulations to limit the first fill of new opioid prescriptions to a seven-day supply; and ongoing prevention education for all physicians and prescribers. Furthermore, unless otherwise noted, the legislation also applies to all commercial health plans for individual, small group and large group policies and HMO contracts issued or renewed on or after January 1, 2017.

The mandate consists of four parts:

1. Limitations on Initial Opioid Prescriptions – prohibits providers from issuing initial prescriptions of a schedule II, III or IV opioid for acute pain for more than a seven-day supply.

2. Clinical Review Criteria for Coverage of Substance Abuse Disorder Treatment – requires utilization review agents to use evidence-based and peer-reviewed clinical criteria approved by the New York State Office of Alcohol and Substance Abuse Services;

3. Emergency Supply for Opioid Addiction Detoxification or Maintenance Treatment — requires large group insurance policies which provide medical, major medical or similar comprehensive type coverage to provide coverage for medication for the detoxification or maintenance treatment of a substance-use disorder approved by the FDA for the detoxification or maintenance treatment of the substance-use disorder. The benefit mandate applies without regard to whether the policy otherwise covers prescription drugs.

4. Insurance Coverage of Inpatient Services for Substance Use Disorders — amends current law to expressly provide that the required coverage of inpatient services includes “unlimited medically necessary treatment” for substance-use disorder treatment services provided in residential settings.

Specific ramifications of the legislation for providers, members

To reduce unnecessary access to opioids, the legislation prohibits providers from issuing initial opioid prescriptions for acute pain for more than a seven-day supply, with exceptions for chronic pain and other conditions. Treatment of acute pain typically only requires a short course of treatment. The regulation stipulates that a member pay a maximum of one copay in the same 30-day period if any refill is required within the same period. Members will be charged a full copay when the prescription is filled. If a refill is needed during the same 30-day period, no additional copay will be collected.

Addiction Treatment Services NYSEnhanced addiction treatment services. Current insurance law mandates that individual and group policies that provide hospital, major medical or similar comprehensive coverage offer coverage for inpatient services for the diagnosis and treatment of substance-use disorder, including detoxification and rehabilitation services. This legislation amends current law to expressly provide that the required coverage of inpatient services includes “unlimited medically necessary treatment” for substance-use disorder treatment services provided in residential settings. Members should see no change to current benefits since coverage of residential treatment was expressly referenced in the federal Mental Health Parity Final Regulations which were effective July 1, 2014.

Emergency five-day supply for opioid withdrawal. The law requires that policies covering prescription drugs for medication for the treatment of substance-use disorder provide immediate access – without prior authorization – to a five-day emergency supply of such medications where an emergency condition exists. Members will be charged a full copay at the time a prescription is filled. If a refill is needed within the same 30-day period, no additional copay will be collected.

 

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