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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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08/24/2009
Dx: 296.90 300.3 301.83
CPT 90806
Symptoms anxiety, anger, depression, couples distress, empathic difficulties, self-esteem
Discussed judgement - oriented to place
impaired, anger, poor, time, person,
Prognosis Fair
Progress to Date Moderate
Treatment Plan Continue Family Therapy
Continue Group Therapy
PHI Pam was on time for today's meeting. Her mood was much better for most of the
week, with a few exceptions. She discussed practicing and being quite successful at
being non-judgmental this week. Paying attention to this skill helped her to realize
how pervasive her judgments are and she was able to see the consequences of
being this way.
She also discussed some ongoing issues with her husband and we strategized ways
of dealing with them effectively.
We will meet again next Monday, 8/31.
08/31/2009
Dx: 296.90 300.3 301.83
CPT 90806
Symptoms anxiety, monetary worries, anger, depression, couples distress,-empathic difficulties,
Discussed self-esteem conduct JadgeMent -
self-doubt, impaired, problems, impulsivity, poor,
oriented to time, person, place
Prognosis Fair
Progress to Date Moderate
Treatment Plan Continue Family Therapy
Continue Group Therapy
PHI Pam was early for today's session. Her mood was fair. SHe had a good week with
her husband, but stillexpresses doubt as to the future of their relationship. She feels
trapped in her marriage for several reasons, particularly financial, and is uncertain
how to remedy this situation. We tied our discussion into the mindfulness she is
presently discussing in group. They are focusing on the HOW skills right now, so we
discussed how being One-Mindful, Non-Judgmental, and Effective can help her with
her marriage. She seemed to respond well to this discussion.
Nicholas A. Psy. D. - PHI Printout for xxxxxx xxxxxxxx 8/24/2009 - 12/8/2009
Cavuoto,
FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012
NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
11 west 42nd street
new york, ny 10036
BLUECRoss BLUESHIELO
MENTAL HEALTH PARITY (aka "Timothy's Law")
On December 22, 2006, the governor of New York signed Senate BIII8482 or "Timothy's
Law"
Into Law as Chapter 748 of the Laws of 2006. Effective on January 1, 2007, this law
amended the Insurance Law to require group health insurance policles that provide inpatient
benefits to provide benefits for mental illness.
Note that anywhere biologically based mental Illness/serious emotional disturbances is
mentioned, Itis applicable to large groups and only small groups that have purchased
the optional rider. See question 2 below regardina what applies to small vs. large
moups. .
'I. What "Timothy's Law?"
is
Law"
"Timothy's is a new New York state law requiring health plans that issue group
insurance providing inpatient benefits to provide expanded coverage to children and
adults for inpatient and outpatient mentat health services comparable to those services
provided for medical care.
2, What are the basic provisions outlined in Timothy's Law?
• insured person under a large or small inpatient benefits
Every group policy providing
has an annual minimurn of 30 days of Inpatient care in a hospital and 20 outpatient
days of active treatment for mental illness.
* The state willsubsidize the cost of this benefit forgroups with 50 or fewer
providing
eligible employees (smalf groups),
• Larger groups (over 50 eligible have to provide an additional layer of
employees)
coverage. The additional coverage includes: (1) treatment, comparable to medical
treatment, for adults and children who have been diagnosed with "biologically based
illness"
mental which is defined as schizophrenla/psychotic disorders, major
depression, bipolar disorder, absessive-compulsive disorder, delusional disorders,
panic disorder, buJimia and anorexia; and (ii)additional coverage for children (under
age 18) with serious emotional disturbances who have been diagnosed with attention
deficit disorder, disruptive behavior disorder, or pervasive development disorder and
where one of the following behavior/risk factors exists: serious suicidal symptome or
other·life-threatening, self-destructive behaviors; significant psychotic symptoms
(halluolnation, delusions, bizarre behaviors); behavior caused by emotional
disturbances that place the child at risk ofcausing personal injury or significant
property damage; or behavior caused by serious emotional disturbanoes that place
the child at substar1tial risk of removal frorn the home.
• The benefits are subject to other terms and conditions of the comparable to
policy
other medical benefits such as co-payments and deductibles, coinsurance, provider
network limitations, and the medical management or utHizMian review of claims. (i.e.
mental health claims are to be covered at the same cost as other medical services;
parity means the same co-payments, coinsurance and deductibles.)
• In addition to the 30 inpatient days/20 outpatient days smalt groups
coverage, can,
at their option, purchase the expanded coverage rider.
Law?"
3. What is the effective date of "Timothy's
The new law was passed was effective January 1, 2007. We have begun implementing
the new law as of this date; however, due to the late date in which the billwas signed
Into law (12/22/06), implementation and compliance have been difficult.Please be
assured that we are using our best effortsto comply with the new [aw. The Insurance
Department, which has primary responsibility for implementing the law, is in the process of
developing the regulations and policies to govem the new law,
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4. How will my benefits change under the new law?
How your benefits will change will depend on what your current benefits are and what
type of contract you have.
Small Group: Ifyou are a member of a smaff group (50 or fewer eligibleemployees), you
will have coverage for at least 30 fnpatient/20 outpatient days per year, Ifyou already
have coverage for 30 inpatient/20 outpatient days per year, then your benefits will not
likely change, except that the cost sharing (such as co-payments) for these visits willlikely
change. The co-payment for officevisits will be the specialty provider co-payment under
your contract. Health plans are also required to give small groups the option to purchase
("rnake available") the additional coverage for biologically based mental inness and
children with serious emotional disturbances as dsscribed above,
Large Group: If you are a member of a large group, you willhave at least 30 inpatient/20
outpatient days per year, plus additional coverage for biolegically based mental illness
and serious emotlonel disturbances In children. The biologically based inental illnessfor
which fullparity is required is:
• schizophrenla/psychotic disorders
• major depression
• bipolar disorder
• delusional disorders
• panic disorders
• obsessive compulsive disorder
• buHmla
• anorexia
Additionally, large group health plans are required to provide coverage with full parity for
children under the age of 18 who have been diagnosed with the following serious
emotional disturbances:
• attention deficitdisorders (ADD),
• disruptive behavior or
disorders,
• pervasive development disorders (PDD)
A-NQ where any one of the following behavlor/rlsk factors exists:
• serious su!c!de! syrnptoms or other self-destructive
life-threatening, behaviors,
• significant psychotic symptoms bizarre
(halluchetian, delusions, behaviors),
• behavior caused emotional disturbances that placed the child at risk of
by
causing personal injury or significant property damage, or
• behavior caused emotional disturbances that placed the child at substantial
by
risk of removal frorn the household
Direct Pay and Government Prograrns: Ifyou are covered under an HMO direct pay
contract, Healthy New York or Child Health Plus cantract1 your benefits will not change.
The new law does not apply to these types of contracts.
Hospital Only Contracts: As written, the law requires hospital only contracts to cover office
visitsfor mental health. All partles appear to agree that this Is a drafting error, but stands
In the law unless Itchanges. We have shared with the Department the difficultiesIn
Implementing such a benefit.
5. VVitithe new law affect my premiums?
Premiums will inost likely increase under the new law. We are Inthe process of
determining the premium rate increase of the new benefits. Our prerrüum rate Increases
will need to be submitted to the Insurance Department before they are put In place. This
may require sorne retroactive premium adjustments.
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6. Can you provide specifics?
Again, We are In the process of determining the premium rate increases for the new
benefits.
• in we provide benefits at least as rich as the 30 visit/20visit minimum
general, already
requirements under Tlinothy's Law.
• For In-network nost for basic medical benefits tends to be lower than
PPO, sharing
the mental health cost sharing, so equanzing the cost sharing would increase
premiums slightly.
• For HMO the cost forbasic medical benefits tends to be
products, sharing
comparable or higher than the mental health cost sharing, so equalization would tend
to decrease prerniums slIghtly.
• coverage for the based mental illness and children with serious
Adding blologically
emotional disturbances will also slightly increase costs for all products.
• For large we Intend to Increase our premium rates to cover the additional cost
, groups,
to claims.
• For small the state will subsidize the cost of the 30 Inpatient and 20
groups, providing
outpatient vlslts and the cost sharing equalization, even for groups already providing
mental health benefits, so costs would likelydecrease for these groups, white at the
same time Empire Is made whole through the subsidy payments from the state,
Groups opting to add coverage for biologically based mental Illness and chhdren with
serious emotional disturbances would pay for itthemselves. We intend to increase
our premium rates to cover this additional cost,
• Our premium rate Increases will need to be submitted to the Insurance Department for
prior approval before they are put In place. This may require some retroactive
premium adjustments.
7. Will the state pay the cost of the premium Increase for small groups?
The law requires the state to cover the cost of providing the 30 Inpatient/20 outpatient
benefit for small groups.
How this subsidy will be applied has not yet been determined. The state willpick up the
extra cost of providing that for groups with 50 or fewer eligible employees.
• The mechanics of how this will be Implemented are still discussed.
being
• The state's super|ntendent of insurance Ischarged with a mechanism to
developing
cover the cost of additional premiums for small groups.
• The Insurance Department has stated that Itcannot deal with 450,000 sman groups
directly and therefore intends to use the Plans to process the subsidy.
• Itstated that the process could work as follows: Plans would set the premium for the
small groups - but not charge the that premium
group
• The Department would then determine the number of small
retrospectively group
members enrolled by the Pian for a period of time (such as a month or a quarter) and
reimburse the Plan the appropriate premium.
• The Plans wHl continue to discuss alternative proposals with the Department,
8. When will members becorne entitled to the new benefit?
A health plan issued on or renewed as of January 1, 2007 has the new benefits in effect
now. A health plan Issued or renewed any time after January 1, 2007, has these new
benefits effective on that date.
9, How do the new benefits work?
The treatment for biologically based mental (Uness/serious emotional disturbances with
children counts against the 30 inpatient/20 outpatient benefit. In other words, the 30
inpatient/20 outpatient day limit Is the base benefit and applies to all coverage. Members are
only entitled to additional coverage for the biologically based conditions and children with
serious emoticñal disturbances once the 30 inpatient/20 outpatient flmIt has been exhausted.
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NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019
10. What does parity mean?
itmeans that benefits must be provided comparable to other benefits under the benefit
contract except for the limitations permitted (30 inpatient/20 outpetient), Limits may not be
Imposed on mental heath that are not imposed on their benefits under the plan, For example:
1. Ifthe contract provides for both in- and out-of-network coverage, then this applies
to mental health treatment as well. Formerly itwas common that many non-HMO
contracts would have both in- and out-of-network benefits but ONLY mental health
was covered in-network, but this Is no tonger permitted.
2. ifthere is the medical plan co-payment of $20, then the mental health co-payment
must be no more than $20. Itcan be less than $20, but no more than $20.
11. How will providers be impacted?
Because the Plan has not had time to change its systems to reflectthe new law, we will need
to work closely with providers as the changes are impiamêñtsd. Claims willgenerally have to
be adjusted retrepe vely so that the apprüpriate reimbursement is given and the
appropriate cost sharing Is imposed.
Providers should be assured that mental health benefits willbe covered for group members In
compliañce with this new law, but that there may be some inadvertent errors resulting in
denials while our systems are being updated to implement the law that willneed to be
adjusted on the back end.
12. How wlil this mandate Impact members of the State, City and Federal Employer
Program?
Mental Health benefits for membsrs of the State Empire Plan are covered by GHI, so while
the mandate does apply to them, Itwill be administered by GHL GHl willtherefore do the
required notice mailing. On the other hand, we also are the insurer for the State for an HMO
plan. For this plan, we do administer the HMO benefits; we will administer the mandate; and
we will be doing the required notice mailing.
The Federal Employee Program is not covered under the NY State Mental Health Parlty
Mandate,
Mental Health bene11ts for the NY City Indemnity plan are covered by GHI, so while the
mandate does apply, itwill be administered by GHI. GHI will do the required notice mailing.
On the other hand, we also are the insurer for the City for HMO, EPO and PPO plans; for
these plans, we will administer the mandate and will be doing the required notice maillng.
Servk:es pnwidedby EmpireHeatihChoiceHMO, Inco and/or
Empire HealthchoiceAssurance,Inc., licensees
of the Blue
Cross and Blus Shield Association,
an association Blue Cross and Blue Shield Plans.
of independent
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FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 P a FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 dd n | p . 0 ? d d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 / & [ e4 d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. 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NO. 85 RECEIVED NYSCEF: 01/10/2019 d d & Aø‰ o ½ d *• -"h-- - -M-.. h. -- - d -h h b . h d h h=h • g = • .d• • •. d •=.hc• d • h• • •n= n d= =ndhn • •.• •• • ••• •• •=.• • • o . • • •h h FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 p ? a a 71 g FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 .• uh u , •, . • • d ! -- . h••. • •, h h • h •. . d • • • • ! FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 P> M AM(M ik . 0 4 þÜ & lÁ0 S rvay & o Q c o FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 d d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 0 d la d ^ c FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 d & - - a a -•.r • a • ••p •• •h• ••••W• - • dd IhzI •.d• d•• •• a • •• •• a FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 n. .-•.P. .h HE -.-• •..h FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 C c . W •h 1*. * *** * " ™* " * "" h u •a • d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 08/24/2009 Dx: 296.90 300.3 301.83 CPT 90806 Symptoms anxiety, anger, depression, couples distress, empathic difficulties, self-esteem Discussed judgement - oriented to place impaired, anger, poor, time, person, Prognosis Fair Progress to Date Moderate Treatment Plan Continue Family Therapy Continue Group Therapy PHI Pam was on time for today's meeting. Her mood was much better for most of the week, with a few exceptions. She discussed practicing and being quite successful at being non-judgmental this week. Paying attention to this skill helped her to realize how pervasive her judgments are and she was able to see the consequences of being this way. She also discussed some ongoing issues with her husband and we strategized ways of dealing with them effectively. We will meet again next Monday, 8/31. 08/31/2009 Dx: 296.90 300.3 301.83 CPT 90806 Symptoms anxiety, monetary worries, anger, depression, couples distress,-empathic difficulties, Discussed self-esteem conduct JadgeMent - self-doubt, impaired, problems, impulsivity, poor, oriented to time, person, place Prognosis Fair Progress to Date Moderate Treatment Plan Continue Family Therapy Continue Group Therapy PHI Pam was early for today's session. Her mood was fair. SHe had a good week with her husband, but stillexpresses doubt as to the future of their relationship. She feels trapped in her marriage for several reasons, particularly financial, and is uncertain how to remedy this situation. We tied our discussion into the mindfulness she is presently discussing in group. They are focusing on the HOW skills right now, so we discussed how being One-Mindful, Non-Judgmental, and Effective can help her with her marriage. She seemed to respond well to this discussion. Nicholas A. Psy. D. - PHI Printout for xxxxxx xxxxxxxx 8/24/2009 - 12/8/2009 Cavuoto, FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 ZTŽ T FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 od dy d ed1 en eU .. . FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 h h d h - • *• h ••h •• •• - h•.+n hh == ah• • •n • - --. h- z ----.--+ ,- h --hh • E ------ - ' n hEn +- -d- hh & - - dd d hh a , • h- h h-h- *h * d- -h 1 z- . . n --+ n •n • • • . • h h• FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 A^9 Å vÅ at dÄ u FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 w h FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 ! FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 . . 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NO. 85 RECEIVED NYSCEF: 01/10/2019 J P W s FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 P S df n o ' a 4 t CR dh d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 u M an d d +--- - ½n I • ht-- - - - Ed -- - - I •• h-dE--- I p d • . ••-.4. ½h dEhh- .•b• •• • • - h- -- • , ,h- ---a-h I ----n - 3 •*•• • • •• • h •• v•h E E Hh h+ - • • d - h d I II • •• • • • • a• •• •• a •• •• •• n n • • En • •L hd =- •Ed½ h+- •• d - - -I - -- - Eh E zu hI •• • aa u u• u •• • ™ * • aa •• un+ -- - hI - - . d- - n - a- " ™" " a " = * • d- E - + T * ** ' - " 3 • • • • • • n• • • d a • d.M n h -. •h d • - • • •• • ••• . • d FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 11 west 42nd street new york, ny 10036 BLUECRoss BLUESHIELO MENTAL HEALTH PARITY (aka "Timothy's Law") On December 22, 2006, the governor of New York signed Senate BIII8482 or "Timothy's Law" Into Law as Chapter 748 of the Laws of 2006. Effective on January 1, 2007, this law amended the Insurance Law to require group health insurance policles that provide inpatient benefits to provide benefits for mental illness. Note that anywhere biologically based mental Illness/serious emotional disturbances is mentioned, Itis applicable to large groups and only small groups that have purchased the optional rider. See question 2 below regardina what applies to small vs. large moups. . 'I. What "Timothy's Law?" is Law" "Timothy's is a new New York state law requiring health plans that issue group insurance providing inpatient benefits to provide expanded coverage to children and adults for inpatient and outpatient mentat health services comparable to those services provided for medical care. 2, What are the basic provisions outlined in Timothy's Law? • insured person under a large or small inpatient benefits Every group policy providing has an annual minimurn of 30 days of Inpatient care in a hospital and 20 outpatient days of active treatment for mental illness. * The state willsubsidize the cost of this benefit forgroups with 50 or fewer providing eligible employees (smalf groups), • Larger groups (over 50 eligible have to provide an additional layer of employees) coverage. The additional coverage includes: (1) treatment, comparable to medical treatment, for adults and children who have been diagnosed with "biologically based illness" mental which is defined as schizophrenla/psychotic disorders, major depression, bipolar disorder, absessive-compulsive disorder, delusional disorders, panic disorder, buJimia and anorexia; and (ii)additional coverage for children (under age 18) with serious emotional disturbances who have been diagnosed with attention deficit disorder, disruptive behavior disorder, or pervasive development disorder and where one of the following behavior/risk factors exists: serious suicidal symptome or other·life-threatening, self-destructive behaviors; significant psychotic symptoms (halluolnation, delusions, bizarre behaviors); behavior caused by emotional disturbances that place the child at risk ofcausing personal injury or significant property damage; or behavior caused by serious emotional disturbanoes that place the child at substar1tial risk of removal frorn the home. • The benefits are subject to other terms and conditions of the comparable to policy other medical benefits such as co-payments and deductibles, coinsurance, provider network limitations, and the medical management or utHizMian review of claims. (i.e. mental health claims are to be covered at the same cost as other medical services; parity means the same co-payments, coinsurance and deductibles.) • In addition to the 30 inpatient days/20 outpatient days smalt groups coverage, can, at their option, purchase the expanded coverage rider. Law?" 3. What is the effective date of "Timothy's The new law was passed was effective January 1, 2007. We have begun implementing the new law as of this date; however, due to the late date in which the billwas signed Into law (12/22/06), implementation and compliance have been difficult.Please be assured that we are using our best effortsto comply with the new [aw. The Insurance Department, which has primary responsibility for implementing the law, is in the process of developing the regulations and policies to govem the new law, FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 4. How will my benefits change under the new law? How your benefits will change will depend on what your current benefits are and what type of contract you have. Small Group: Ifyou are a member of a smaff group (50 or fewer eligibleemployees), you will have coverage for at least 30 fnpatient/20 outpatient days per year, Ifyou already have coverage for 30 inpatient/20 outpatient days per year, then your benefits will not likely change, except that the cost sharing (such as co-payments) for these visits willlikely change. The co-payment for officevisits will be the specialty provider co-payment under your contract. Health plans are also required to give small groups the option to purchase ("rnake available") the additional coverage for biologically based mental inness and children with serious emotional disturbances as dsscribed above, Large Group: If you are a member of a large group, you willhave at least 30 inpatient/20 outpatient days per year, plus additional coverage for biolegically based mental illness and serious emotlonel disturbances In children. The biologically based inental illnessfor which fullparity is required is: • schizophrenla/psychotic disorders • major depression • bipolar disorder • delusional disorders • panic disorders • obsessive compulsive disorder • buHmla • anorexia Additionally, large group health plans are required to provide coverage with full parity for children under the age of 18 who have been diagnosed with the following serious emotional disturbances: • attention deficitdisorders (ADD), • disruptive behavior or disorders, • pervasive development disorders (PDD) A-NQ where any one of the following behavlor/rlsk factors exists: • serious su!c!de! syrnptoms or other self-destructive life-threatening, behaviors, • significant psychotic symptoms bizarre (halluchetian, delusions, behaviors), • behavior caused emotional disturbances that placed the child at risk of by causing personal injury or significant property damage, or • behavior caused emotional disturbances that placed the child at substantial by risk of removal frorn the household Direct Pay and Government Prograrns: Ifyou are covered under an HMO direct pay contract, Healthy New York or Child Health Plus cantract1 your benefits will not change. The new law does not apply to these types of contracts. Hospital Only Contracts: As written, the law requires hospital only contracts to cover office visitsfor mental health. All partles appear to agree that this Is a drafting error, but stands In the law unless Itchanges. We have shared with the Department the difficultiesIn Implementing such a benefit. 5. VVitithe new law affect my premiums? Premiums will inost likely increase under the new law. We are Inthe process of determining the premium rate increase of the new benefits. Our prerrüum rate Increases will need to be submitted to the Insurance Department before they are put In place. This may require sorne retroactive premium adjustments. FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 6. Can you provide specifics? Again, We are In the process of determining the premium rate increases for the new benefits. • in we provide benefits at least as rich as the 30 visit/20visit minimum general, already requirements under Tlinothy's Law. • For In-network nost for basic medical benefits tends to be lower than PPO, sharing the mental health cost sharing, so equanzing the cost sharing would increase premiums slightly. • For HMO the cost forbasic medical benefits tends to be products, sharing comparable or higher than the mental health cost sharing, so equalization would tend to decrease prerniums slIghtly. • coverage for the based mental illness and children with serious Adding blologically emotional disturbances will also slightly increase costs for all products. • For large we Intend to Increase our premium rates to cover the additional cost , groups, to claims. • For small the state will subsidize the cost of the 30 Inpatient and 20 groups, providing outpatient vlslts and the cost sharing equalization, even for groups already providing mental health benefits, so costs would likelydecrease for these groups, white at the same time Empire Is made whole through the subsidy payments from the state, Groups opting to add coverage for biologically based mental Illness and chhdren with serious emotional disturbances would pay for itthemselves. We intend to increase our premium rates to cover this additional cost, • Our premium rate Increases will need to be submitted to the Insurance Department for prior approval before they are put In place. This may require some retroactive premium adjustments. 7. Will the state pay the cost of the premium Increase for small groups? The law requires the state to cover the cost of providing the 30 Inpatient/20 outpatient benefit for small groups. How this subsidy will be applied has not yet been determined. The state willpick up the extra cost of providing that for groups with 50 or fewer eligible employees. • The mechanics of how this will be Implemented are still discussed. being • The state's super|ntendent of insurance Ischarged with a mechanism to developing cover the cost of additional premiums for small groups. • The Insurance Department has stated that Itcannot deal with 450,000 sman groups directly and therefore intends to use the Plans to process the subsidy. • Itstated that the process could work as follows: Plans would set the premium for the small groups - but not charge the that premium group • The Department would then determine the number of small retrospectively group members enrolled by the Pian for a period of time (such as a month or a quarter) and reimburse the Plan the appropriate premium. • The Plans wHl continue to discuss alternative proposals with the Department, 8. When will members becorne entitled to the new benefit? A health plan issued on or renewed as of January 1, 2007 has the new benefits in effect now. A health plan Issued or renewed any time after January 1, 2007, has these new benefits effective on that date. 9, How do the new benefits work? The treatment for biologically based mental (Uness/serious emotional disturbances with children counts against the 30 inpatient/20 outpatient benefit. In other words, the 30 inpatient/20 outpatient day limit Is the base benefit and applies to all coverage. Members are only entitled to additional coverage for the biologically based conditions and children with serious emoticñal disturbances once the 30 inpatient/20 outpatient flmIt has been exhausted. FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 10. What does parity mean? itmeans that benefits must be provided comparable to other benefits under the benefit contract except for the limitations permitted (30 inpatient/20 outpetient), Limits may not be Imposed on mental heath that are not imposed on their benefits under the plan, For example: 1. Ifthe contract provides for both in- and out-of-network coverage, then this applies to mental health treatment as well. Formerly itwas common that many non-HMO contracts would have both in- and out-of-network benefits but ONLY mental health was covered in-network, but this Is no tonger permitted. 2. ifthere is the medical plan co-payment of $20, then the mental health co-payment must be no more than $20. Itcan be less than $20, but no more than $20. 11. How will providers be impacted? Because the Plan has not had time to change its systems to reflectthe new law, we will need to work closely with providers as the changes are impiamêñtsd. Claims willgenerally have to be adjusted retrepe vely so that the apprüpriate reimbursement is given and the appropriate cost sharing Is imposed. Providers should be assured that mental health benefits willbe covered for group members In compliañce with this new law, but that there may be some inadvertent errors resulting in denials while our systems are being updated to implement the law that willneed to be adjusted on the back end. 12. How wlil this mandate Impact members of the State, City and Federal Employer Program? Mental Health benefits for membsrs of the State Empire Plan are covered by GHI, so while the mandate does apply to them, Itwill be administered by GHL GHl willtherefore do the required notice mailing. On the other hand, we also are the insurer for the State for an HMO plan. For this plan, we do administer the HMO benefits; we will administer the mandate; and we will be doing the required notice mailing. The Federal Employee Program is not covered under the NY State Mental Health Parlty Mandate, Mental Health bene11ts for the NY City Indemnity plan are covered by GHI, so while the mandate does apply, itwill be administered by GHI. GHI will do the required notice mailing. On the other hand, we also are the insurer for the City for HMO, EPO and PPO plans; for these plans, we will administer the mandate and will be doing the required notice maillng. Servk:es pnwidedby EmpireHeatihChoiceHMO, Inco and/or Empire HealthchoiceAssurance,Inc., licensees of the Blue Cross and Blus Shield Association, an association Blue Cross and Blue Shield Plans. of independent FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 . cS T . a 4 p I E - IE -- - - n h IIHMd- -d z - - - -- - - FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 l^ . . .. . FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019 . u . ^ ed 0 [ c? FILED: SUFFOLK COUNTY CLERK 01/10/2019 10:08 PM INDEX NO. 026910/2012 NYSCEF DOC. NO. 85 RECEIVED NYSCEF: 01/10/2019