Overview:

The New York State (NYS) Office of Mental Health (OMH), in coordination with the NYS Department of Health (DOH) and NYS Office of Addiction Services and Supports (OASAS), monitors Managed Care Organizations (MCOs) on an ongoing basis to ensure they are properly providing behavioral health services to their members. The State monitors each MCO for compliance with the following:

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

Focused surveys are part of the State’s oversight activities. These surveys identify issues that may require compliance monitoring and corrective actions. If the State finds a MCO non-compliant with state and federal laws and regulations or the Medicaid Model Contract, the MCO will be issued a citation.

A citation is issued through:

• Statement of Deficiency (SOD): Cites violation of state and federal laws, rules, or regulations.
• Statement of Finding (SOF): Cites failure to comply with the Medicaid Model Contract.

The MCO can respond with a Plan of Correction (POC), outlining how the MCO will address each identified deficiency or violation.

Surveys, issued citations, corrective actions, and additional enforcement penalties

Behavioral Health Claims Denial Focused Surveys (2017- present)

The State conducts ongoing monitoring of behavioral health claims payments, denial trends, and adherence to the reimbursement of government rates mandated by law (Chapter 57 of the Laws of 2017, Part P, 48-a.1). Through the review and analysis of monthly claims denials reports submitted by the MCOs and provider complaints between December 2017 and May 2018, the State identified claims were being persistently denied for specialty behavioral health services. The specialty behavioral health services most impacted were Assertive Community Treatment (ACT), Personalized Recovery Oriented Services (PROS), Comprehensive Psychiatric Emergency Program (CPEP), Partial Hospitalization (PH) and Adult Behavioral Health Home and Community Based Services (BH HCBS). The State also discovered that MCOs with behavioral health subcontractors had the highest denial rates for behavioral health services.

Beginning in August 2018, the State conducted a comprehensive review, root cause analysis, of the MCOs’ monthly claims reports from 2017 and forward to address the high denial rates for specialty behavioral health services. The root cause analysis found that some MCOs that delegated claims payment and prior authorization responsibilities to a third-party behavioral health subcontractor had a higher rate of inappropriate behavioral health claims denials. During the root cause analysis, MCOs were issued 20 citations for failure to properly oversee their behavioral health subcontractor, inappropriately denying claims for no prior authorization when prior authorization was prohibited or not required, and failure to pay behavioral health claims correctly and timely. In May 2019, the State conducted a follow-up examination including document review, claims denial analysis, and interviews with MCO leadership to ensure compliance with the MCO-developed Plans of Correction and to verify the cited issues have been resolved. State reviewers identified repeat non-compliance and newly identified areas of non-compliance. Based on the findings, the State issued 11 repeat citations and 14 new citations. The State then pursued enforcement action against the five noted MCOs due to persistent non-compliance.

The five MCOs have agreed to the State’s findings. The violations and monetary penalties are below:

• Affinity Health Plan, Inc. was fined $349,500 for failure to provide adequate oversight of delegated management function and failure to reimburse providers at Medicaid Fee-for- Service (FFS) and/or Ambulatory Patient Group (APG) rates. The behavioral health services not paid at the required rate included ACT, PROS, CPEP, Adult BH HCBS and PH.
• Amida Care, Inc. was fined $232,000 for inappropriately denying behavioral health claims and failing to comply with prompt pay requirements related to statutorily required interest. The behavioral health services denied incorrectly included Adult BH HCBS, ACT, and PH.
• EmblemHealth was fined $422,000 for failure to provide adequate oversight of their behavioral health subcontractors to correct inappropriate claims denials due to human processing error and to pay claims for behavioral health services at required minimum rates. EmblemHealth and behavioral health subcontractors failed to pay government rates as a result of inappropriate claims denials and failure to properly configure the claims adjudication system and the behavioral health subcontractor inappropriately denied claims for behavioral health services due to human error. The behavioral health services with inappropriate claims denials included PH, CPEP, ACT and PROS.
• MetroPlus HealthPlan, Inc. was fined $584,000 for failure to effectively implement their Plan of Correction by permitting the behavioral health subcontractor to pay claims at less than the NYS mandated government rates, failure to provide adequate oversight of the behavioral health subcontractor, and failure to effectively reimburse providers at the Medicaid FFS and/or APG rates. The behavioral health services which were not paid at the government rate included ACT, PROS, PH, CPEP and Adult BH HCBS.
• MVP HealthPlan, Inc. was fined $1,080,000 for failure to provide adequate oversight of their behavioral health subcontractor, failure to pay government rates due to underpaying behavioral health claims and failing to effectively implement their Plan of Correction by not ensuring the behavior health claims were paid at the required rate. The behavioral health services not paid correctly included PROS, CPEP, and Adult BH HCBS.

Behavioral health claims denial citations, accepted corrective actions, and stipulations and orders are available through DOH .

Mental Health Parity Focused Surveys (2018 - present)

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires health insurance plans offering mental health (MH) and substance use disorder (SUD) benefits to provide coverage for those services that is comparable to and no more restrictive than medical or surgical (M/S) benefits (Learn more about MHPAEA)

MCOs must perform self-assessments of payment and approval practices and report results to the State.

Mental health parity citations and accepted corrective actions are available through DOH .

Key Staffing Focused Surveys (2021 - present)

MCO behavioral health key staff requirements are outlined in the Medicaid Managed Care Model Contract, Adult Behavioral Health Policy Paper, Children’s CFTSS Policy Paper, and Children’s System Transformation Requirements and Standards for adults and children. MCOs are required to provide written notification to the State within seven calendar days after the effective date of termination or resignation of any key staff. The notice shall include the name of an interim contact person, plan for replacing the key person, and an expected timeframe for replacement. Failure to provide such notification to the State result in a citation.

Behavioral health key staffing citations and corrective actions are available through DOH .

For questions regarding citations, please contact the BHO Mailbox.