December 16, 2024
Recently the NYS Council has been leading the charge to compel Governor Hochul to include a proposal in her upcoming State of the State presentation and subsequently in her ’25-’26 executive budget proposal that would require NYS to ensure state regulated commercial insurers (other than those that are self-funded) are required to offer the same range of mental health and substance use disorder services for New York’s children, youth and families as those that are currently available to Medicaid beneficiaries, beginning with HCBS and CFTSS services. We have requested complete parity between the two insurance programs and in our meetings we have highlighted these two services specifically due to the ongoing youth mental health crisis and the fact that these services are designed to provide a wide range of interventions that can ameliorate the need for more acute services – but only if they are available.
Providers are struggling to offer CFTSS and other services for children, youth and families due to poor reimbursement rates that make it difficult to fully staff HCBS and CFTSS services. This directly impacts network adequacy. At the end of the day it is the insurer that (if mandated to provide these services) could find themselves having to raise reimbursement rates in order to meet the Network Adequacy (NA) standards but only if the state robustly enforced the rules. Relying on market forces in no way makes up for robust advocacy designed to improve reimbursement rates without having to rely on health insurers to first feel the pinch but it is another way to force the issue and to this point, the state is (hopefully) in the last phase of updating NA standards so there will be some pressure from that end too.
We have pitched the children, youth and families commercial proposal as another courageous next step the Governor can take as follow up to her historic leadership and ultimate enactment of Part AA – the commercial rate mandate that is effective as of Jan. 1, 2025. Here the Governor has another opportunity to expand access to care in our service delivery system. Frankly, our request is an excellent way for her to continue to demonstrate her leadership and concern for New York’s kids and families.
Collectively, the April 2024 enacted state budget included 16 new insurance mandates (mostly coverage mandates) that are now or will soon be in effect. Health plans are sounding the alarm and this has made the political climate for securing additional coverage mandates more challenging at this moment in time given the constant complaining and lobbying by the insurance industry.
The NYS Council has also prioritized and had numerous discussions with government leaders about our growing concern for commercial beneficiaries who are increasingly unable to afford ever escalating copays and deductibles associated with accessing care. Employers are increasingly choosing to ‘self-fund’ insurance for their staff as a way to lower costs, however federal insurance policies omit self-funded plans from certain critical statutory requirements such as the new commercial rate mandate and to this point the state has not acted to step in.
We have been arguing for copay and deductible waivers for commercial beneficiaries who would otherwise be faced with impossible decisions over whether to seek care or put food on the table. In this particular argument we have focused attention on the ongoing opioid crisis and the inability of a growing number of New Yorkers to bear the financial burdens associated with seeking life saving treatment and support through the public mental hygiene system due to increasing cost share responsibilities despite a raging overdose epidemic that continues to devastate families and communities, beginning with those who are underserved or marginalized.
For over two decades the NYS Council has led the discussion and advocacy fight to increase and expand access to care, to increase rates and to expand coverage through our work to secure major policy reforms that include the following achievements (list below). We are proud of our long track record of success in this area and we are eternally grateful to our member-partners who have demonstrated a long term commitment and scarce resources to address these issues. We will continue to work to transform our systems of care and make on demand access to care that is fairly reimbursed and adequately staffed the standard in order to keep our commitments to New Yorkers who need and deserve our services:
Guardrails & Protective Metrics in Medicaid Managed Care
· 2010: Secure Rate Congruency between MMC and FFS rates in BH via advocacy with Deb Bachrach (SMD) and Executive (Chapter 111 of the laws of 2010
· 2011-13: Budget includes carve-in of most behavioral health services into MMC (Chapter 59 of the laws of 2011); Drafted language and led advocacy effort to secure Medicaid APG gov’t rates for more BH services to be paid in MMC (Chapter 56 of the laws of 2013)
· 2013: Drafted and secured budget language requiring surveillance and monitoring of protective metrics in MMC such as requirements for the state to surveil network adequacy; Also secured budget language for a report to the Governor and Legislature on the transition of BH services to MMC (Chapter 56 of the laws of 2013)
· 2015: Co-led advocacy effort to secure APG government rates for behavioral health services for Child Health Plus enrollees (Chapter 57 of the laws of 2015)
Enforcement of Behavioral Health Expenditure Targets (BHET) in MMC
· 2020-21: Pursued state by issuing 25 FOILS through NYS Council attorneys and several meeting with the Executive Chamber to inform of intent to litigate
· 2022: MCO Enforcement actions identifying failure to recoup overpayments from MMC plans that did not meet BHET/MLR requirements
· 2022: Budget includes language related to BHET recoupment and reporting requirements (Chapter 57 of the laws of 2022)
o $500 million collected to date resulting in rate increases for OASAS and OMH providers
Addressing Commercial Rate Disparities in BH
· 2015-20: NYS Council advocacy at all levels of government (Executive Chamber, state agencies (DFS, DOH, OMH, OASAS), AGs, Legislature to press for action on commercial rate disparity compared to MMC, and pressure on state to increase surveillance, monitoring and enforcement
· 2021-24: Shopped language on commercial rate mandate
· 2024: Budget includes language requiring commercial insurers to pay at no less than the MMC (APG) rates for behavioral health services (Chapter 57 of the laws of 2024)
Network Adequacy and Access to Care Wins
· NYS Council supported a series of insurance reforms included in the 2023-24 Budget including updated network adequacy standards for behavioral health services under Medicaid and commercial insurance (Chapter 57 of the laws of 2023)
· 2024: NYS Council participates in regulatory process to update network adequacy standards
· 2022: NYS Council issued HMA CCBHC Demo Financial Analysis resulting in the executive proposal to expand CCBHC Demo Program in NYS to a total of 39 sites by July 1, 2025.
Other Insurance Reforms
· 2019: NYS Council drafted and led advocacy effort resulting in the passage of a law requiring timely payment (A2787, Chapter 451 of the laws of 2019)
· 2022-23: NYS Council draft and led advocacy effort resulting in the passage of a law requiring transparency and publication of NYSDOH changes to model contract under Medicaid for managed care plans (S1348, Chapter 100 of the laws of 2023)
· 2022-23: NYS Council advocacy for BH carve out of MMC and (previous to this) proposal for competitive procurement of MMC plan contracting; Enacted budget in 2022-23 required a Report on potential for competitive procurement (Chapter 57 of the laws of 2022); In 2023, NYS Council Executive Director interviewed by Boston Consulting Group Report (attached) and her comments are incorporated into the Report (attached).