Overview:

The New York State Department of Health (DOH) monitors Managed Care Organizations (MCOs) on an ongoing basis for compliance with:

• Public Health Law Articles 44 and 49
• 10 NYCRR Part 98
• The Medicaid Model Contract for those plans offering Medicaid
• Other State and federal laws and regulations as applicable

As part of its MCO oversight activities, DOH conducts focused surveys which identify specific issues requiring compliance monitoring and correction if needed. When DOH finds through a focused survey that a MCO is not complying, it issues a citation to the MCO. A citation may be a Statement of Deficiency (SOD) for failure to comply with law or regulation or a Statement of Finding (SOF) for failure to comply with the Medicaid Model Contract.

Once a citation is issued, the MCO has an opportunity to review and respond with a plan to correct the non-compliance. Once this plan is accepted by DOH, the citation and corrective action is final and posted to this website.

Mental Health Parity and Addiction Equity Act (MHPAEA) Focused Surveys (2018 - present)

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires that coverage for mental health/substance use disorders (MH/SUD) cannot be more restrictive or more expensive than medical/surgical coverage. (Learn more about MHPAEA)

MCOs must perform self-assessments of their payment and approval practices and report the results to the State. The results of the focused survey form 2018- present are available through DOH .

Behavioral Health Claims Denial Root Cause Analysis Focused Surveys (2017- present)

Focused surveys were initiated to examine MCO behavioral health prior authorization and claims adjudication processes. The results showed there was a high rate of improper denials for some MCOs who delegated prior authorization and claims adjudication of behavioral health services to a third-party vendor. The non-compliant MCOs were issued citations for:

• failure to properly oversee their vendor
• inappropriately denying claims for no prior authorization when prior authorization was not required
• failure to pay behavioral health claims correctly and timely.

The citations and accepted corrective actions are available through DOH .

For questions regarding citations, please contact bmccsmail@health.ny.gov.