Overview:

The New York State Office of Mental Health, in coordination with the state Department of Health and state Office of Addiction Services and Supports, 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 applicable state and federal laws and regulations

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 an MCO to be non-compliant with a law, regulation, or Medicaid Model Contract requirement, the MCO will be issued a citation.

A citation is issued through:

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

The MCO may respond with a corrective action plan (CAP), outlining how they will address each identified deficiency or finding.

View State Issued Behavioral Health Citations by MCO

Behavioral Health Claims Denial and Government Rate Compliance Focused Surveys

MCOs are required to correctly pay for medically necessary behavioral health services. The State monitors MCOs’ management of behavioral health services, including coverage and payment, by routinely reviewing claims data and provider complaints.

When the State identifies that an MCO has inappropriately denied necessary behavioral health services, or paid for those services below the required rates, citations are issued. Monetary enforcement actions have also been taken against MCOs due to continued payment and denial issues.

Review the behavioral health claims denial and government rate compliance citations, accepted CAPs, and enforcement actions (stipulations and orders).

Behavioral Health Parity Focused Surveys

Behavioral health parity refers to federal and state protections, such as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), requiring specific types of health insurance plans provide coverage for behavioral health services in a comparable way to physical health services.

The State conducts routine surveys to ensure compliance. MCOs are required to perform self-assessments and demonstrate behavioral health parity through data reports and supporting documentation. When an MCO fails to comply with the federal and/or state protections, citations are issued. Monetary enforcement actions have also been taken against MCOs for ongoing failure to meet behavioral health parity requirements.

Learn more about MHPAEA

Review the behavioral health parity citations, accepted CAPs, and enforcement actions (stipulations and orders).

Behavioral Health Key Staffing Focused Surveys

MCOs are required to staff specific key behavioral health positions. The State monitors behavioral health staffing by requiring MCOs to submit bi-annual reports. MCOs must provide written notification to the State within seven calendar days of a staff person leaving the key position. The notification must include the name of a temporary contact person, plan for replacing the key person, and an expected timeframe for the position to be permanently filled.

The State reviews staffing reports for any inconsistencies and tracks MCOs’ staffing notifications. Citations are issued when an MCO fails to provide staffing notifications and updates to the State as required.

Staffing requirements are outlined in the following:

• Medicaid Managed Care Model Contract
• Adult Behavioral Health Policy Paper
• Children’s CFTSS Policy Paper
• Children’s System Transformation Requirements and Standards[EL5.1] (adults and children)

Review the behavioral health key staffing citations and accepted CAPs.

Behavioral Health Network Adequacy Focused Surveys

MCOs are required to maintain a network of participating providers. They must ensure that their network includes the minimum number of providers to meet the behavioral health needs of their members. MCOs are required to report provider network information on a quarterly basis to the Provider Network Data System (PNDS).

MCO provider networks are monitored through the review of PNDS and based on service type, location, and minimum network requirements, consistent with the Medicaid Model Contract. Citations are issued when an MCO fails to meet the required network standards for specific BH services.

Review the behavioral health network adequacy citations and accepted CAPs.

For questions regarding citations, please contact the BHO Mailbox.