February 7, 2023
Like all areas of executive budget analysis, the details are what count and we are continuing to slog our way through the language and appropriations to ensure we understand and can provide all members with accurate information. We ask for your patience as we continue to fine tune our documents.
There is an OMH Budget Briefing for advocates later today, and an OASAS Budget Briefing tomorrow. No doubt we will need to make tweaks to what we have already shared. In the meantime, here’s what we have learned so far about the executive budget insurance proposals of import to our members and the individuals they serve:
According to state officials, the insurance proposals embedded in the executive budget (discussed below) are designed to increase access to care, shake up current market forces, and improve existing requirements on commercial insurers to include:
A Network Adequacy provision that would:
- explicate in regulations specific standards insurers must comply with, to ensure timely and appropriate access to care for their insured;
- require health plans that cannot identify an ‘in network’ provider for an insured to pay the available OMH or OASAS licensed provider at the negotiated rate and if there is no negotiated rate, pay the provider at the Medicaid rate. State feels this will disrupt current market forces and help providers gain leverage in the commercial insurance market, and force commercial payers to expand their ‘in network’ provider network.
Note: At this point, the OMH and OASAS Commissioner’s Emergency Waivers no longer carry through any telehealth flexibilities that were granted during COVID-19 epidemic, pertaining to reimbursement for telehealth services – permanent regs issued by both state agencies have embedded any state derived flexibilities however, in the executive budget, there is language that makes it very clear that commercial payers MUST pay at parity for telehealth services. Provision requires commercial plans to pay the same for telehealth services provided by Article 31, 32 and and Article 36 (crisis stabilization centers that are jointly licensed by OASAS and OMH) regardless of where the practitioner or the client is located for the appointment.
In addition, there are several provisions dealing with Utilization Review including language that would require insurers to use either the LOCUS or another OMH approved tool, to conduct UR. LOCUS is an instrument developed by the American Association of Community Psychiatrists. For any MH services, either locus or another OMH approved criteria must be used. Plans would be given one year to begin using the LOCUS as the mandatory tool for use.
Right now plans can’t do Prior Authorization or concurrent review for 14 days for kids and adult inpt. psych but an exec budget provision would extend this to include crisis residential services (not OMH community residences) for both kids and adults, and inpatient psych. For adults, this provision codifies the standards laid out in an OMH document that sets forth Best Practice Standards (released in 2020 and linked here: https://omh.ny.gov/omhweb/bho/docs/best-practices-manual-utilization-review-adult-and-child-mh-services.pdf) . Also, plans cannot conduct concurrent review for 30 days for most adults (also embedded in the OMH Best Practices document linked above).
Private Right of Action
Budget includes language that permits clients to sue when the commercial insurer violates a parity provision. In this case, the care recipient is entitled to damages at either minimum amount of damages ($1,000) or actual damages and compensation for attorneys fees.
Expansion of what services must be covered by commercial insurance to include:
- OMH Residential (medically monitored, not community residences)
- Crisis Residential
- OCD/Eating Disorders residential services
- Residential Treatment Facilities (RTFs)
- *Mobile Crisis Intervention
- Care Coordination
- Critical Time Interventions
*Mobile Crisis services must be covered just like ambulance services – no Prior Auth, no limits as to which Mobile Crisis provider can be called.
*In the case of use of Out of Network mobile crisis services, the client would be held harmless for in-network cost sharing, and if the provider and plan can’t agree on reimbursement, the provider will be able to submit the matter for independent dispute resolution consistent with ‘No Surprises Act’.
Executive budget proposal firms up commercial insurance coverage for Opioid Overdose Reversal medications to include those that are prescribed as well as those that can be obtained over the counter.
Other provisions related to Access to Care:
School-based MH clinics will be paid at no less than Medicaid rate or (if provider prefers) a negotiated rate, by commercial insurers. If the school-based clinic is out of network, the family will be held harmless for in-network cost sharing, and there will be no balance billing permitted.