May 18, 2021

Below is a transmittal that was sent to New York’s Essential Plans as result of advocacy performed by the NYS Council and our members to resolve an access to care issue in which certain health plans participating in the Essential Plan marketplace were denying claims for Family Counseling provided to Essential Plan beneficiaries (Essential Plans 1-4) without a plausible explanation.  

We are grateful to OMH Division of Managed Care as well as our colleagues at DOH for their support and responsiveness on this matter.   And, a big thank you is due to Diane Novy at The Jewish Board and many other ‘NYS Council Billing Geeks’ who helped us push this boulder up the hill. 

Yay team!

See below and attached.

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Transmittal here and attached:

As you aware, Essential Plan covers outpatient mental health services, as outlined in section XII of the Essential Plan Subscriber Agreement.  I have attached a copy of that section to this email.  These services include family counseling, including CPT code 90847 (family counseling with enrollee present) and Code 90846 (family counseling without the enrollee present).  

It would be appreciated if you could confirm that your systems are configured to process claims for and cover these services by emailing me with a reply.

Thank you

Kelly Lamendola
Director, Office of Marketplace Counsel

518-408-1975 (direct line)
kelly.lamendola@health.ny.gov
NYStateofHealth.NY.gov
Division of Legal Affairs
NYS Department of Health

On Tue, May 18, 2021 at 9:05 AM Lamendola, Kelly M (HEALTH) <kelly.lamendola@health.ny.gov> wrote:

Dear Lauri and Diane,

To follow-up on the issue of coverage of family counseling under the Essential Plan, Margaret Middleton, our Director of Plan Management, has followed-up with all Essential Plan issuers in writing to confirm coverage of outpatient mental health services, as outlined in Section XII of the Essential Plan Subscriber Agreement.  These services include family counseling, including CPT Code 90847 (family counseling with enrollee present) and Code 90846 (family counseling without the enrollee present). 

We appreciate you bringing this issue to our attention.  If you encounter further issues with access to family counseling in Essential Plan, please let us know.

Thank you.

Kelly Lamendola

The contents of this email are confidential and protected by attorney-client privilege, as attorney work-product, or by other privileges or provisions of law.

Kelly Lamendola
Director, Office of Marketplace Counsel