September 19, 2024

Attached please find a useful resource from the Medical Society of the State of New York (MSSNY) describing the various types of health insurance products in New York State, the state regulator that oversees the insurance product and how to determine which entity ‘owns’ complaints and other issues you may be having with insurers doing business in New York.

Please note:  This document was released in 2021 (as certain new requirements on insurers were being implemented by the state). While I can’t guarantee the phone numbers / email addresses provided have remained the same since 2021, the general information as to where to turn when you have a problem is accurate.  If you need specific information I would be happy to help.

Note:  OMH recently established a commercial mailbox where providers can submit questions regarding commercial insurance.  The email address is:  commercial-billing@omh.ny.gov.  At the end of the day, complaints regarding commercial insurance must be filed with the Department of Financial Services (DFS), we encourage you to “cc” the OMH commercial mailbox with your complaint information.

As we have been broadcasting to our members, self-funded insurance plans are not subject to the new law that mandates insurers pay (at a minimum) Medicaid APG rates for services covered under provider contracts with commercial plans.  Self-funded healthcare coverage is regulated by the US Dept. of Labor—there is a link in the document for directing complaints to that agency.It is also noted that the 2021 law referenced in MSSNY’s document (11 NYCRR 52.69) requires that ID cards for comprehensive health insurance coverage include the phrase “fully insured coverage.”  Additionally, when an insurer is acting as an administrator on behalf of a group that provides self-funded health care coverage and the insurer’s name appears on the health insurance identification card, the ID card must include the phrase “self-funded coverage.  

To benefit from the new commercial rate mandate, a provider must be ‘in network’ with the commercial plan that covers your client in order for eligible commercial services to be reimbursed at the Medicaid APG rate.