November 9, 2023

Although the total fines are low, the enforcement (discussed below) is still significant and a credit to the hard work and perseverance of every NYS Council member agency that has filed a complaint against a plan that has failed to pay the APG government rate on time and in full, as required by law.

Congratulations to all and THANK YOU!

Subject: GOVERNOR HOCHUL ANNOUNCES $2.6 MILLION IN FINES AGAINST INSURANCE COMPANIES FOR FAILING TO ADEQUATELY COVER BEHAVIORAL HEALTH SERVICES

GOVERNOR HOCHUL ANNOUNCES $2.6 MILLION IN FINES AGAINST INSURANCE COMPANIES FOR FAILING TO ADEQUATELY COVER BEHAVIORAL HEALTH SERVICES

New York Issues $2.6 Million in Total Fines to Five Insurance Companies for Violating State Regulations and Medicaid Rate Payment Law

Unlawful Denials by Managed Care Health Plans Pose Unnecessary Barriers for New Yorkers Seeking Behavioral Health Care

Governor Kathy Hochul today announced more than $2.6 million in penalties against five Medicaid managed care health plans following a comprehensive examination of their reimbursement of behavioral health service claims. New York State levied these fines after the carriers repeatedly and inappropriately denied claims or failed to pay for specialty behavioral health services at the rates required by law.

“No New Yorker should face unnecessary barriers to mental health care, especially if their insurance carrier fails to meet their legal obligation to cover these essential services,” Governor Hochul said. “My administration is committed to holding insurance companies accountable to ensure New Yorkers can access the critical mental and behavioral health care that they need.”

The fines resulted from the Health Plan Focused Survey Results for Behavioral Health Claims Denials, a report compiled by the Office of Mental Health. The denials were most frequently for care provided by Assertive Community Treatment; Personalized Recovery Oriented Services; Comprehensive Psychiatric Emergency Program, partial hospitalization; and Adult Behavioral Health Home and Community Based Services.

The companies penalized include:

• Affinity Health Plan, Inc., which was fined $349,500 for failing to provide adequate oversight of delegated management function and failing to reimburse providers at required rates.
• Amida Care, Inc., which was fined $232,000 for inappropriately denying behavioral health claims and failing to comply with prompt pay requirements.
• EmblemHealth, which was fined $422,000 for failing to correct inappropriate claims denials and failing to pay claims at required minimum rates.
• MetroPlus HealthPlan, Inc., which was fined $584,000 for failing to pay claims at required minimum rates; and failing to reimburse providers at the required rates.
• MVP HealthPlan, Inc., which was fined $1 million for failing to pay claims at required minimum rates and failing to reimburse providers at required rates.

The Office of Mental Health monitors managed care organizations on an ongoing basis to ensure they are properly providing behavioral health services to their members. Focused surveys identify issues that may require compliance monitoring and corrective actions.

The agency worked in partnership with the New York State Department of Health to issue the regulatory action. The Health Department has the legal authority to apply fines and enforce compliance in the Medicaid program.

Office of Mental Health Commissioner Dr. Ann Sullivan said, “Managed health care plans have a legal obligation to cover legitimate claims for behavioral health services and reimburse this treatment at the rates prescribed by law. The companies that continue to flout these regulations are imposing a formidable barrier that ultimately discourages New Yorkers from getting the mental health care they need. New York State is holding Medicaid insurers accountable and those insurers failing to comply with the law will face significant penalties.”

Department of Health Commissioner Dr. James McDonald said, “New York State has implemented a strategy under the direction of Governor Hochul that holds insurance companies accountable for not adequately covering behavioral health treatment. These penalties demonstrate a multi-agency approach to overcome the obstacles New Yorkers face from receiving the mental health care services they need.”

Under Governor Hochul’s landmark plan to improve New York’s continuum of mental health care, the state has undertaken several measures that ensure New Yorkers are covered by their insurance when accessing critical mental health care. Legislation adopted as part of the FY 2024 State Budget prohibits commercial insurance plans from denying coverage for medically necessary inpatient services, including life-saving care coordination services.

Commercial plans are also now required to adopt appointment availability and geographic accessibility standards for behavioral health services, and to cover all services provided by school-based mental health clinics. In addition, Governor Hochul secured legislation requiring providers to pay at least the Medicaid reimbursement rate for care provided at these clinics.

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