NEW YORK (WWTI) – Announced by Governor Kathy Hochul that following a comprehensive examination of five Medicaid managed Care Health Plans they have received a $2.6 million in penalties based on their reimbursement of Behavioral Health Service claims.

“No New Yorker should face unnecessary barriers to mental health care, especially if their insurance carrier fails to meet their legal obligation to cover these essential services,”

Governor Kathy Hochul

These fines have been placed after New York State found that the carriers repeatedly and inappropriately denied claims or failed to pay for specifically Behavioral Health Services at the rates required by law.

“My administration is committed to holding insurance companies accountable to ensure New Yorkers can access the critical mental and behavioral health care that they need.”

Governor Kathy Hochul

The fines have resulted from a report compiled by the Office of Mental Health, Health Plan Focus Survey Results For Behavioral Health Claims Denials.

The most frequent denials were for care provided by:

  • Assertive Community Treatment;
  • Personalized Recovery Oriented Services;
  • Comprehensive Psychiatric Emergency Program, partial hospitalization; and
  • Adult Behavioral Health Home and Community Based Services.

The companies penalized include:

  • Affinity Health Plan, Inc.: fined $349,500;
  • Amida Care, Inc.: fined $232,000;
  • EmblemHealth: fined $422,000;
  • MetroPlus HealthPlan, Inc.: fined $584,000; and
  • MVP HealthPlan, Inc.: fined $1 million.

It is the duty of the Office of Mental Health to monitor Managed Care organizations on an ongoing basis so that they can properly provide Behavioral Health Services to their members. Issues identified in focused surveys may require compliance monitoring and corrective actions.

To issue the regulatory action the Office of Mental Health partnered with the New York State Department of Health, which has legal authority to apply fines and force compliance in the Medicaid Program.

With new Legislation, adopted as part of the FY 2024 State Budget and as part of Governor Kathy Hochul’s plan to improve New York’s continuum of mental health care, it is now prohibited for commercial insurance plans to deny coverage for medically necessary inpatient services including life-saving care coordination services.

Commercial plans will now have to adopt appointment availability and Geographic accessibility standards for Behavioral Health Services along with covering all services provided by school-based clinics. Additionally, legislation requires providers to pay at least the Medicaid reimbursement rate for care provided at the clinics.