December 8, 2023

Cheat Sheet:  DoH regulates and oversees the state’s Medicaid Program while DFS has oversight responsibility for commercial insurance.  

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The NYS Council is thankful to AG Letitia James for her ‘secret shopper’ examination of health plan directories that revealed what we already knew – that commercial health plans are not complying with Network Adequacy standards, and the quarterly Provider Network Directory reports they are required to file with the state are wildly inaccurate.  To add insult to injury,  the state is failing to monitor these lists for accuracy and to take action against bad actors.  

In the interview below, I tried to move the issue to the ongoing disparity between the Medicaid and commercial rates that results in what we have repeatedly characterized as state sanctioned discrimination during our many meetings with the Department of Financial Services (DFS).  

What’s missing here – what’s been missing for over a decade is meaningful surveillance, monitoring and enforcement of Network Adequacy and other ‘protective’ metrics regulators are supposed to measure to understand whether New Yorkers can actually find the care they need.  It will be important to follow this latest development to see whether any of the regulators enforce against those insurers that advertise robust networks when the reality is something very different.  For the moment, enforcement is where the rubber meets the road and it has been anemic at best.  

On a hopeful note, the ’22-’23 enacted state budget includes a provision that requires state regulators to propose updated Network Adequacy standards.  The NYS Council had our first conversation with DFS leaders regarding Network Adequacy standards that have not been updated in decades some 10 years ago and we have intensified our advocacy over many years.  The enacted budget finally included language that requires the state to propose new Network Adequacy standards by the end of the month.  At the same time, the federal government is pushing health plans on this issue.   Stand by for more.

Among mental health providers listed in New York health plan directories, 86% did not take in-network patients — exposing sparse access to mental health and substance use services across the state, a new report shows.

Attorney General Letitia James’ office released a report yesterday showing that only 14% of health plans’ listed behavioral health clinicians accepted appointments for in-network services. The rest were “ghosts,” meaning that they were either out-of-network, unable to take new patients or unreachable entirely.

The results come from a survey of 13 health plans across New York state, including Aetna, Cigna, UnitedHealthcare and Empire BlueCross BlueShield.

“By not maintaining accurate directories as required by law, health plans are making it harder for New Yorkers, especially the most vulnerable among us, to get mental health care,” James said in a statement. “I am calling on health plans to rapidly address this problem and help us tackle the mental health care crisis.”

One in five adults in New York lives with a mental illness, according to the report. But despite a high need for care, access remains patchy. Last year, 29% of New Yorkers with anxiety or depression reported an unmet need for counseling or therapy. There are even fewer services for youth.

The attorney general held hearings to further investigate mental health care access in New York state, and testimony from more than 100 patients and providers revealed a “broken system,” the office said. Parents reported months of searching for psychiatrists to provide care to their children and providers called attention to low reimbursement rates that have forced them to stop accepting certain commercial insurance plans.

Health plans in New York are required by law to keep up-to-date provider directories, including information about whether or not a provider is accepting new patients. Law also requires insurers to make sure that their network of providers is robust enough to meet demands for care.

The attorney general’s office conducted a secret shopper survey to explore whether health plan directories offered patients reliable access to mental health care. Researchers called nearly 400 providers, including psychiatrists, psychologists, nurse practitioners, licensed mental health counselors and social workers, all of which were listed in health plan directories as accepting new patients.

Across all health plans, just 56 providers offered an appointment, the researchers found. The percentage of ghost providers varied across health plans. Cigna had the lowest rate of ghost providers at 35%. All of the provider listings in MVP’s network were ghost providers, the report found.

Eric Linzer, president and chief executive of the New York Health Plan Association, which represents insurers across the state, said that “health plans are acutely aware of the behavioral health crisis that both children and adults are facing,” as well as the chronic shortage of mental health workers.

“The challenge here is that the delivery system is currently having real challenges to meet behavioral health demands,” Linzer told Crain’s. “The focus should be on ways to increase the number of available providers,” and not placing the responsibility on just one segment of the health care system, he added.

But behavioral health providers say poor access is driven by more than just a shortage of available providers—it’s linked to inadequate rates paid by commercial insurers for behavioral health services.

Lauri Cole, executive director of the New York State Council for Community Behavioral Healthcare, said that commercial insurance often pays providers a fraction of what Medicaid pays for behavioral health care because the state dictates Medicaid rates. The result is that some providers have to cut back on the number of patients with commercial insurance they accept or hire fewer providers to keep their doors open.

“If New York is wondering why we continue to have an abundance of overdose in our communities, or why children are sitting in emergency departments not being able to find community-based care upon discharge, this is one of the primary reasons,” Cole said.

The attorney general recommended that state regulators conduct frequent audits of health plan directories, mandate wait time standards to ensure timely access to care and upscale enforcement for health plans that violate directory requirements.

The findings come as the state prepares to propose new regulations around network adequacy — which aim to ensure that health plans can provide enough services to meet demand. The Department of Financial Services, Department of Health, Office of Mental Health and the Office of Addiction Services and Supports are required to propose new network adequacy regulations for mental health and substance use services by the end of this year. —Amanda D’Ambrosio