Testimony for Public Hearing Senator Phillip Boyle

Heroin & Prescription Drug Epidemic: Connecting Dots to Youth

November 13, 2013

philip-boyleNancy Beckett-Lawless

Seafield Center

7 Seafield Lane,

Westhampton Beach NY 11978


Committee: Senate Standing Committee on Alcoholism and Drug Abuse


Good Afternoon Senator Boyle and members of the Committee.  My name is Nancy Beckett-Lawless and I am Director of Provider Relations for Seafield Center.  I am Co-chair of the Managed Care Committees for two New York State provider organizations: ASAP – Association of Alcoholism and Substance Abuse Providers and ATPA – Addiction Treatment Providers Association.  I also Chair the Long Island Insurance and Managed Care Committee and am co-founder of the East End Clinical Connection, a group of behavioral health professionals who provide addiction and mental health treatment to residents living on the east end of Long Island.


First, I would like to recognize and thank Senator Boyle and his colleagues in the Senate, and the rest of the Legislature, for their support of the Attorney General’s successful initiative in passing a law at the forefront of the prescription drug epidemic, the  I-Stop Legislation, which we have already seen is effective in curbing the over prescribing and misuse of prescription pain medication.  I would also like to acknowledge the role New York State played in achieving Federal Parity by leading the way with the passage of Timothy’s Law in 2006 which preceded the successful passage of The Mental Health Parity and Addiction Equity Act of 2008. New York State always leads the way in assuring quality care is delivered to our most vulnerable citizens, and we thank you for that.


I am here today to ask you to step up one more time to help us close an unintended loophole created by Parity, the issue of medical necessity. The actions I suggest will not cost the State of New York any additional money, but could save the lives of countless young people who overdose from opiates when they are turned away from treatment too early …or not admitted to treatment at all…..because they cannot access the treatment benefits of their own insurance policy by not meeting the proprietary “medical necessity criteria” demanded by their Insurance Company or Managed Care Organization. Every Insurance Company has their own criteria and has a fiduciary interest in denying care!

Young people and others are being denied detox and inpatient rehab every day. *Give the example of the young person assessed in Mineola after his first overdose, approved for detox in a hospital for 3 days and then refused  INP, relapsed on the first night out, assessed again in Mineola for INP and again refused. Admitted to IOP on a Friday, overdosed the 3rd time on Sunday evening, died on the 3rd OD and was brought back with paddles only to be denied the 3rd time for not meeting medical necessity. His family sent him to Florida and when he returned he had no benefits left! He was taken off the parents insurance and put on Medicaid and what should have been the “payer of last resort” once again became the payer of “first resort.” Cost shifting due to medical necessity.


We need to do 2 things:  First create a definition of medical necessity that meets the needs of the residents of NYS and the State.  2nd We need to enforce the use of our State LOC determinator, LOCTDAR 2.0 or its equal, for all level of care placement by insurance companies doing business in NYS.


New York State has designated the Office of Alcoholism and Substance Abuse Services (OASAS) as the single state agency responsible for the coordination of state-federal relations in the area of addiction services. Section 32.01 of Mental Health Law authorizes the Commissioner to adopt and promulgate any regulation necessary to implement and effectively exercise the powers and perform the duties conferred by Article 32 of the Mental Hygiene Law. Section 32.07 (4) (e) of the NYS Mental Hygiene Law discusses the regulatory power of the Commissioner and gives “the Commissioner, in consultation with the Commissioner of Health, the ability to adopt standards including the necessary rules and regulations including ……..determining the necessity or appropriate level of admission, controlling the length of stay and the provision of services, and establishing methods and procedures for making such determination.”  OASAS regulations provide for the use of the LOCADTR 2.0 or equal, to determine the level of care placement.


So…by law OASAS has the authority to determine medical necessity utilizing LOCADTR 2.0 or equal. Therefore, if we amend existing NYS Mental Hygiene Law to include a provision which states; All insurance companies doing business in NYS are required to use NYS Level of Care determinator , the LOCATDR 2.0 or any tool approved by OASAS, when making medical necessity decisions and level of care recommendations.

How else can we further expand existing NYS Law to insure NYS residents with Substance Use Disorder (SUD) will receive

appropriate care within the guidelines of Federal Parity?  To answer this question let us first look at how NYS currently defines medically necessary treatment.


  • According to NYS Social Services, 365-a, New York Law defines “medically necessary medical, dental, and remedial care, services, and supplies” in the Medicaid program as those necessary to prevent, diagnose, correct, or cure conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person’s capacity for normal activity, or threaten some significant handicap and which are furnished an eligible person in accordance with State Law.


Officials in the state’s Medicaid agency report that this definition applies to both fee-for-service and managed care populations.


In this definition lies a problem. These criteria are not sufficiently clear or unambiguous.


Today I would like to recommend we develop a new definition of medical necessity for NYS law that would be a model definition of Medical Necessity meeting the needs of the residents and the State.


I am going to give you examples of what 2 States have implemented that have been upheld over time and proven not to cost those States considerable money:

In 1999 The Stanford Research Project presented preliminary findings to a workshop of key stakeholders in California and developed a model definition for medical necessity that was adopted by State Medicaid Program and private plans.

They defined “Medical Necessary” shall mean health care services that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating, an illness, injury or disease or its symptoms, and that are;

a) In accordance with generally accepted standards of medical practice.

b) Clinically appropriate, in terms of type, frequency extent, site and duration, and considered effective for the patients illness, injury or disease.

c) Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic result for the diagnosis or treatment of that patient’s illness, injury or disease.


For our consideration today “generally accepted standards of medical practice” mean standards and guidelines outlined by our own NYS Department of Health, NYS Office of Alcohol and Substance Abuse Services and NYS Office of Mental Health.


Another example: In 1988 Pennsylvania enacted Act 152 legislation under the Department of Public Welfare which established placement criteria for use by Drug and Alcohol Programs “governing the type, level, and length of care or treatment” of drug and alcohol clients including hospital detoxification, as basis for standards for services provided. This criteria was updated in 1999 with the development of Pennsylvania Client Placement Criteria which remains in effect today. In 1989 Pennsylvania enacted ACT 106 which to date remains hugely successful and has been upheld through passage of Federal Parity.  PA Act 106 requires all commercial group plans, HMO’s and Children’s Health Insurance to provide mandated minimums on detox, rehab and outpatient treatment when authorized by a licensed physician or licensed psychologist and referred to a licensed in-state program.


This Law not only meets Federal Parity requirements but exceeds them, has been upheld, and remains in effect today.


The recommendation for a new definition of medical necessity is all about unifying the language when anyone writes a policy to provide insurance coverage for New Yorkers. This step will cost NYS exactly “zero dollars” to the taxpayer and if done appropriately will reduce premiums and costs to the plans by keeping people out of emergency rooms with overdoses, heart attacks caused by drug use, countless admits due to alcohol and drug related accidents, and less dollars needed to fund the criminal justice system.  Simple language levels the playing field and is good social policy for NYS.


How often does the Legislature get to craft policy that saves lives, supports the health and welfare of the citizenship and does not cost the taxpayers a single dollar!


Thank you for your time and consideration.


Nancy Beckett-Lawless

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