NYS Council on the Move re: BH Carve-Out

December 11, 2023

I wanted to share the sign on letter the NYS Council drafted and then circulated to our peer associations along with our proposal to carve out outpatient mental health and substance use disorder services from the state’s Medicaid managed care program, and a Fact Sheet.   The Sign On Letter went to the Executive, DoB, OMH, OASAS, DoH and others on Thursday night.

The NYS Council has worked for a decade to ensure Medicaid beneficiaries seeking mental health and substance use disorder services licensed under OASAS and OMH can find these services on demand and at the right level of care through the state’s public mental hygiene system.  Over time we have intensified our advocacy efforts to compel the state to robustly surveil, monitor and enforce all of the laws, guidance and contract provisions that govern the carve in of our services; however, DoH/OHIP continue to permit MCOs to break the law and delay or deny reimbursement to providers who are experiencing intense demand for care.

Two years ago, the NYS Council found the state had failed to enforce a contract provision that allowed MCOs to keep overpayments made to them due to their failure to meet a required expenditure target requirement. MCOs were sitting  on hundreds of millions of dollars they had not earned.  Our efforts resulted in $222M in MCO recoupments being returned to OASAS and OMH and used to increase rates across both systems of care.  This was for overpayments made over a two year period however BH services have been carved in for some 8 years.

In August our association surveyed our members.  We had a 50% response rate to a survey that included 66 questions focused on access to care issues.  We confirmed waiting lists for MH and SUD services across the state – not just in small agencies.  Also, there are wait lists for New Yorkers who need to see a prescriber for Medication Assisted Treatment and other medications that (along with counseling/psychotherapy) are considered to be the gold standard for treatment of opioid use disorders and other complex behavioral health conditions.

Most of our members employ (on average) 6 staff that are working in their back offices to chase reimbursement for services rendered months (and sometimes years) ago from MCOs.  They spend on average $400k/year when one considers all of the expenses associated with their continued participation in Medicaid managed care, and they are required to do business with (on average) 8 different MCOs, all with their own requirements on the provider.

With the knowledge that MCOs have been cited by the state over 200 times since 2019, a 2022 Milliman Report found insurers are not complying with state and federal parity laws, and the AG’s ‘secret shopper’ findings regarding ‘ghost networks’, it is time for the state to carve out outpatient MH and SUD services and return them to a Fee for Service reimbursement model. 

This action will not require the state to hire new staff to implement the carve out.  It will return valuable resources to the OASAS and OMH systems of care that cannot meet current demand. This move will NOT block increased penetration of integrated care, nor will it block development of value-based purchasing arrangements.

If you have questions about any of this information, please feel free to contact me at your convenience at 518 461-8200. Lauri