News & Info for NYS Council Members, 9/5

September 5, 2025

Occasionally the NYS Council will survey our members on high priority issues such as workforce shortages, access to care and waiting lists, and health plan compliance (or lack thereof) with the Medicaid APG government rate mandate we secured over a decade ago, and more recently, the new commercial rate mandate (Part AA).   Over the last several months we have been meeting with representatives from the Governor’s Office, DoB, DoH and the O agencies to discuss our ‘ask’ for a carve out of outpatient behavioral health services, and robust and immediate enforcement of the commercial rate mandate, but we need up to date data.

The climate is right for our carve out request but as you know there will be significant opposition from the insurance industry and our new legislation that is being championed by the Senate and Assembly Mental Health/Mental Hygiene chairs.

We need ALL of our members to respond to the survey (linked below) in order to gather the fire power we need to succeed with our carve out campaign.  

Please help us to help you and the individuals and families you serve by completing this important survey:

NOTE:  We have extended the deadline for completion for this survey to September 12.

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Doctors recoup millions in denied claims from insurers

Ethan Geringer-Sameth , Crain’s NY Business, 9/5

Doctors in New York have recovered millions of dollars from insurers in disputes over rejected claims in recent years.

Since 2021, the Medical Society of the State of New York, a physician trade group, has recovered more than $17 million in denied claims from insurance companies, according to the group.

The denials stem from insurers ignoring legally-binding federal determinations, dropping physicians from networks and in some cases simply leaving claims unpaid with no ability to contact a representative, according to the Medical Society. In many cases, services were misclassified, resulting in rejections, while at other times, settled claims were illegally clawed back, the group said.

The recouped payments, which only account for claims secured through the trade group, offer a glimpse into the murky world of health care reimbursement and the tactics deployed by insurance companies to avoid covering the cost of health care.

Approximately $9 million of the recovered funds are the result of insurance carriers categorizing a service as experimental even when the Centers for Medicare and Medicaid Services do not classify them that way, the Medical Society said. Another $7.5 million came from companies taking back funds from claims that were already settled, a practice prohibited by state law. In those cases, insurance companies often send a claim to a collections agency even after it has been adjudicated and settled, according to Dr. Thomas Lee, the Medical Society’s executive vice president.

Some insurers make it difficult to navigate the claims process with bureaucratic hurdles, the company said. One plan has not paid claims worth $739,000 dating back more than a decade to 2013, according to MSSNY. The company, which the group declined to name, made it impossible for doctors to speak with representatives about the unpaid claims, MSSNY said.

At other times, insurers improperly dropped doctors from their networks, resulting in $580,000 in denied claims.

In recent months, the group has also gone after denied claims that have been overturned on the federal No Surprises Act, which went into effect in 2022 and protects patients from certain out-of-network billing. In the last two months, MSSNY has recovered $300,000 from insurers after they failed to pay for services after third-party arbitrators determined they must go through a process under the law known as Independent Dispute Resolution.

Leslie Moran, senior vice president of the New York Health Plan Association, which represents insurance companies, defended the carriers, noting that a majority of claims are paid in full and on time, even as the cost of care rises. In 2023, 74% of the 312 million claims submitted were fully covered, according to the group’s analysis of claims data kept by the state Department of Financial Services.

“From our perspective, this data shows the plans are working very hard to ensure timely and accurate payment of provider claims,” she said.

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New Report on Managed Care and Medicaid  (click on this link for the article)

This week, Physicians for a National Health Program (PNHP) released a report, Removing the Middlemen from Medicaid, with recommendations for states in response to the federal Medicaid funding reduction of $1 trillion over the next decade brought about by H.R.1. The recommendations urge states with “managed care” contracts with large insurers to cancel those contracts and use the savings to protect state Medicaid programs.

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Earlier this week we told you that a House Appropriations committee was going to markup a Labor-HHS FFY26 approps budget.  That was Tuesday at 5.  The Committee marked it up and then passed it out of committee as described below.

Summary:  The approps budget for HHS includes a  6% cut ($7B) across HHS.   The bill includes a 19% cut to the CDC and moves to eliminate the Agency for Healthcare Research and Quality (AHRQ).  New funding is proposed for the Make America Healthy Again (MAHA) initiative, with $100M to support investments in prevention and innovation programs for rural communities, telehealth resources for chronic care, and nutrition services.
Other (proposed) appropriations of note include: 

  • $48M to NIH for biomedical research
  • $3B to the Administration for Strategic Preparedness and Response
  • $515M for rural health, specifically maintaining hospital and physician access
  • $1.85B for community health centers and other primary care services
  • $1.36B for health care workforce development and placement in underserved areas

A summary of the full Labor-HHS proposed budget can be found here:  https://appropriations.house.gov/sites/evo-subsites/republicans-appropriations.house.gov/files/evo-media-document/fy26-labor-health-and-human-services-education-and-related-agencies-subcommittee-summary.pdf

And, here is more detail re:  the Labor-HHS FFY26 approps bill that was passed out of committee earlier this week from Politico (8/3).  But remember:  All of this assumes Congress and work in a bipartisan manner to pass all or most of the 12 approps bills necessary to enact a new federal budget (due October 1).  The likelihood of a federal government shutdown (in full or in part) depends on these next few weeks of negotiations.  

Republicans on a House Appropriations panel advanced a bill Tuesday that would cut the HHS budget by 6 percent for the fiscal year that starts next month, far less than sought by President Donald Trump but enough to prompt united Democratic opposition.

In a 11-7 vote, the House Appropriations Labor, Health and Human Services, Education and Related Agencies Subcommittee approved $108 billion in funding for HHS — a $7 billion decrease from fiscal 2025. Trump had asked for a $31.3 billion cut.

“The bill before you today balances the need for responsible fiscal stewardship while maintaining key investments in biomedical research, schools and public health,” said Rep. Robert Aderholt (R-Ala.), the subcommittee chair.

Aderholt highlighted what he said was an increase in support for rural hospitals and biodefense through the bill and the elimination of diversity, equity and inclusion programs promoted by the Biden administration, as well as the defunding of Planned Parenthood.

“It prohibits any federal funding from going toward enforcing gender identity politics or social or moral or surgical interventions to change a child’s sex,” Aderholt said about the bill.

“This isn’t right-wing extremism. This is mainstream public opinion,” he added.

Democrats opposed the bill and used the occasion to voice their anger about other Trump administration actions, including the firing last week of CDC Director Susan Monarez.

“I cannot support this never-ending attack on our health care, public school system and our workers,” said Connecticut Rep. Rosa DeLauro, the panel’s ranking Democrat.

The details: The bill would keep funding for the National Institutes of Health, the largest funder of health research in the world, at $48 billion, according to a summary Republican appropriators released Monday.

Republicans intend to maintain “America’s edge in basic biomedical research for cures to cancer, Alzheimer’s disease, and rare diseases” and support Trump and Health Secretary Robert F. Kennedy Jr.’s “priority of increasing research for other chronic diseases impacting Americans,” the document says.

The NIH funding is also “a necessary counter to China’s growing threat in basic science research,” the document says.

But DeLauro decried the bill’s nearly $500 million cut to the Advanced Research Projects Agency for Health, which the Biden administration set up as part of NIH to back high-risk, high-reward projects.

The House bill would reduce funding for the Centers for Disease Control and Prevention by nearly a fifth, or some $1.7 billion, to refocus it on communicable diseases “rather than social engineering,” according to Republicans’ bill summary. The White House proposed slashing the agency’s budget by roughly half, also aiming to refocus it on infectious diseases.

Research!America, a lobbying group for universities, disease advocacy groups, physicians’ societies and other organizations that work with the government, praised the panel’s decision to maintain funding for the NIH, but said it was alarmed by the CDC cuts.

“These proposed cuts, coupled with recent turmoil at the agency’s leadership, endanger our nation’s health,” the group said in a statement released before the subcommittee’s vote on the funding bill.

The group also asked the committee to sustain the Agency for Healthcare Research and Quality, an HHS division that tries to improve the quality and safety of health care. Republican appropriators said they were eliminating it because its work was duplicative of other agencies’.

Though Trump prioritized efforts to combat HIV and AIDS in the U.S. during his first term, the House bill would cut funding for the Ryan White HIV/AIDS program, which provides care and support for low-income people with HIV, by some $500 million from the current $2.5 billion. The bill also wouldn’t provide funding for the CDC’s HIV prevention program, which received about $1 billion in fiscal 2025.

The HIV Medicine Association, which represents health care professionals working on HIV, said it thought the bill would “devastate the HIV response in communities across America, upending four decades of progress in ending the HIV epidemic.”

“The first Trump administration proposed a new initiative to end the HIV epidemic, and the second Trump administration on the other hand has abandoned the fight,” DeLauro said.

The subcommittee bill would provide $100 million to Kennedy’s Make America Healthy Again initiative, which Republican appropriators said would allow him “to invest in prevention and innovation programs for rural communities, telehealth resources for chronic care, and nutrition services.”

The bill also would provide $515 million for rural health, which includes increased funding for rural hospitals, specifically targeting facilities at risk of imminent closure and increasing medical residency opportunities, according to the Republican appropriators’ bill summary.

The tax cut legislation Republicans enacted in July previously included a $50 billion fund to help rural hospitals cope with new requirements in the law that Medicaid recipients work, volunteer or go to school, which alongside new restrictions on tactics states have used to increase their federal Medicaid funding are expected to significantly reduce Medicaid funding flowing to hospitals. The state-federal insurance program serves low-income people.

What’s next: The spending bill now goes to the full House Appropriations Committee, which is tentatively expected to mark it up on Sept. 9, Aderholt told POLITICO, though that could change.

It’s uncertain if the bill will become law since it would need to pass both the House and Senate as well. One panel member, Democrat Mark Pocan of Wisconsin, predicted it would not: “We know this bill will never become law. We’re going to continue to play fantasy Congress for the next several weeks.”

Lawmakers have less than a month until government funding expires on Sept. 30, increasing the odds of a government shutdown or of a stopgap funding patch.

Senate appropriators in late July passed an HHS funding bill increasing the department’s budget for the next fiscal year by $446 million compared to this year.

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News from the Legal Action Center:

Hi Lauri-  just wanted to share this new national report that our DC office made about mitigating the worst impacts of Medicaid work requirements:

LAC’s national report — “Protecting People with Substance Use Disorders and Formerly Incarcerated Individuals from Losing Medicaid Coverage: Recommendations on Implementing the H.R. 1 Work Reporting Requirements” — provides a clear framework for how states can best mitigate harm to these particularly vulnerable populations. 

Additionally, on September 18th, our experts will be hosting a webinar to walk through the report and discuss key takeaways — register to join us here.