New York Prohibits Copays at Opioid Treatment Facilities: What Providers Need to Know 

In a significant policy shift, effective January 1, 2023, New York State law (S.5690/A.372) mandates that commercial health insurance plans must no longer impose copayments and coinsurance for services provided at Opioid Treatment Programs (OTPs). This legislative change directly impacts a range of plans, including Qualified Health Plan (QHP), commercial, and Essential Plan products. 

The new regulation defines an “opioid treatment program” as any program or practitioner involved in the opioid treatment of individuals using opioid agonist treatment medication. 

Implications for OTP Providers: 

In response to this policy alteration, Healthfirst is taking the following measures to ensure compliance and transparency: 

1. Claims Reprocessing: 

• Healthfirst is currently in the process of reprocessing OTP claims with a date of service (DOS) from January 1, 2023, onward. The objective is to eliminate member cost-sharing components, including copays and/or coinsurance. Providers can anticipate receiving the allowed amount based on the services rendered. 

1. Member Cost-Share Refund: 

• Providers are required to refund any copays or coinsurance collected from members for OTP services rendered on or after January 1, 2023. This ensures that members are not financially burdened by cost-sharing obligations for these specific services. 

Billing Procedures Remain Unchanged: