State's Medicaid managed care plan compliance improving

ALBANY | Gov. Hochul has announced that all Medicaid managed care plans operating in New York State have improved compliance with rules for fair access to mental health and substance use disorder services, even as the Trump Administration rolls back enforcement of these critical protections. Among the plans reviewed by the New York State Office of Mental Health (OMH), the Capital District Physicians' Health Plan, Inc., and Excellus BlueCross BlueShield were found to be 100 percent compliant with all regulations. "While the Trump Administration sleeps on regulations aimed at ensuring access to critical behavioral health services, New York State has achieved landmark reforms and is holding insurance companies accountable so that all New Yorkers can get coverage for this critical care," Gov. Hochul said. "The gains in compliance we're seeing today reflect our steadfast commitment to ensuring these carriers cover critical mental health services and don't restrict access to care." Last month, the Trump Administration indicated in a federal court filing that it does not intend to enforce certain mental health parity regulations, including rules requiring insurance companies apply fair standards for behavioral health services. These regulations prevent insurers from imposing additional barriers — such as prior authorization requirements or restrictive provider networks — making it harder for patients to access mental health and substance use care as compared to physical health services. In contrast, New York State has been actively taking steps to ensure Medicaid managed care plans are complying with regulations and providing New Yorkers with the coverage they are entitled to receive under law. The State Office of Mental Health reviewed six nonquantitative treatment limitations — provisions that are sometimes manipulated by these plans to restrict access to necessary behavioral health care — and found all carriers in compliance. In addition, OMH's comprehensive and rigorous examination also determined that both the Capital District Physicians' Health Plan, Inc., and Excellus BlueCross BlueShield were fully compliant with all 19 nonquantitative treatment limitations. OMH, however, also found that most managed care plans did not fully demonstrate compliance with other provisions with the Mental Health Parity and Addiction Equity Act. Some continually applied a different rate-setting process for behavioral health services and reimbursing providers for less than they would for medical and surgical services. New York State has worked to hold managed care plans accountable for these violations. During a similar review of behavioral health claims filed between 2018 to 2020, OMH uncovered high levels of inappropriate denials for specialty services claims, including $39 million between December 2017 and May 2018. New York State took enforcement action on all 15 Medicaid managed care plans, issuing a total of 95 citations between 2019 and 2021, resulting in fines to 11 carriers totaling more than $1 million. Resulting fines were used to fund the Community Health Access to Addiction and Mental Healthcare Project, also known as CHAMP. This program is the State's independent health insurance ombudsman program for behavioral health care, which helps New Yorkers access treatment and insurance coverage for substance use and mental health treatment. New York State Department of Health Commissioner Dr. James McDonald said, "Access to harm reduction and mental health services saves lives and the measures taken under Governor Hochul's leadership ensures Medicaid managed care plans are complying with the regulations and are creating no limitations to care for New Yorkers who rely on these services. Access to affordable coverage is a matter of health equity and the State Department of Health will continue to work with our state and local partners to expand access to harm reduction and mental health services and eliminate health disparities in New York State." OMH monitors managed care organizations on an ongoing basis to ensure they are properly providing behavioral health services to their members. The agency works in partnership with the Department of Health, which has the legal authority to apply fines and enforce compliance in the Medicaid program. New York is leading the nation in requiring health insurers to cover behavioral health services and continues to develop tools to ensure these companies are following all applicable laws. New York State's new network adequacy standards will go into effect starting in July, entitling New Yorkers to an initial appointment for behavioral health care within 10 business days of the request, or seven calendar days following hospital discharge. Insurers unable to meet these timeframes will have to offer out-of-network mental health or substance use disorder coverage without increasing the cost for the consumer. The state now also requires commercial insurers to reimburse covered outpatient mental health and substance use disorder services provided by in-network OMH and Office of Addiction Services and Supports facilities at no less than the Medicaid rate. In the FY 2026 Enacted State Budget, Governor Hochul also secured $1 million to ensure that insurers are providing the mental health care coverage policyholders deserve including new resources to strengthen compliance oversight, educating consumers and providers, and investigating and mediating complaints. Gov. Hochul also helped secure a state Medicaid waiver to cover social determinants of health, required commercial and Medicaid health plans to use transparent, nonprofit clinical guidelines and cover all medically necessary treatments.

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State's Medicaid managed care plan compliance improving

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