March 7, 2024

OMH updated its SBMH billing FAQs as of March 1.  See attached for the entire FAQ update.

Of note:

A: It’s at the plans’ discretion whether to require providers to use SBMH rate codes. However, the State recommends that commercial plans adopt the use of rate codes to be consistent with Medicaid which will significantly reduce the administrative and billing burden for providers and plans considering the complications of the APG algorithm.

A: The reimbursement requirement for outpatient care provided by a nonparticipating SBMH clinic licensed pursuant to Mental Hygiene Law Article 31 applies regardless of whether the policy or contract covers out-of-network services.
Answer of note:  In general, SBMH clinics only serve registered students, families, and collaterals. Per the MHOTRS billing guidance, the enhanced rate may not be billed for clients of the satellite who are not enrolled students at the host school.

Answer of note:  The law provides that payment by an issuer to the SBMH clinic is payment in full for the services provided. Further, the SBMH clinic may not charge or seek any reimbursement from, or have any recourse against, an insured for the services provided, except for the collection of in-network copayments, coinsurance, or deductibles for which the insured is responsible under the terms of the policy or contract.

Q:  Regarding the above, does the underlined language mean that an insurer is only permitted to apply in network copayments, coinsurance, and deductibles even if the SMBHC is out of network? As you are aware, some benefit plans may have different out-of-pocket costs for out-of-network and in-network providers. Would a plan collect an in-network co-pay/coinsurance/deductible from an insured who is covered by a plan with no outof-network benefits?

Answer: Correct, the plan may only apply in-network copayments, coinsurance, and deductibles to the SBMH payment, even if the SMBH clinic is out of network.