Final Report on Managed Care Organization Services

Key behavioral health findings from the 2022 Final Report include:

Noncompliance with the Mental Health Parity and Addiction Equity Act:

• New York State issued 95 citations for noncompliance from 2018 to 2020.
• A 2022 survey of MCO documents found that several MCOs repeatedly failed to demonstrate compliance.
• These violations continue to raise concerns about behavioral health access for members.

MCO underspending on Behavioral Health services:

• Managed care organizations are not spending all of their allotted premiums on behavioral health services.
• A review of Behavioral Health Expenditure Target, and Medical Loss Ratio, shows they remitted more than $220 million in allocated premiums back to the state from 2017 to 2020.

High levels of inappropriate claims denials for Behavioral Health specialty services:

• This includes an estimated $39 million between December 2017 and May 2018, which resulted in 20 official citations.

Access to Mental Health Care

A 2022 study showed that New York is outpacing the national average when it comes to providing access to mental health care after visiting the hospital and emergency room.

• The majority of insured New Yorkers visiting the hospital for mental health reasons get follow-up care in 30 days.
• Three out of four New Yorkers with a hospital visit for mental health reasons get follow-up care within 30 days
• Two out of three New Yorkers with an emergency department visit for mental health reasons get follow-up care within 30 days

Managed Care Improvements

New York state continues to make improvements to Managed Care by:

• Adopting a state Medicaid waiver to cover social determinants of health through Social Care Networks.
• Requiring Commercial and Medicaid health plans to use medical necessity criteria that is evidence based, peer reviewed, age appropriate, and approved by OMH, per 14 NYCRR § 514. Learn more about Behavioral Health Parity requirements.
• Mandating commercial and Medicaid health plans to cover out-of-network care at no extra cost if timely in-network care is not available.
• Requiring commercial health insurers to pay a negotiated rate or at least the Medicaid rate that applies to the procedure code for School-Based Mental Health Clinic services provided by OMH-licensed providers.
• Requiring commercial insurers to reimburse covered outpatient mental health and substance use disorder services provided by in-network OMH and OASAS facilities at no less than the Medicaid rate.
• Requiring commercial and Medicaid health plans cover telehealth for mental health services and reimburse at in-person rates.

These changes are part of the state’s larger effort, including a $1 billion investment to transform its mental health system, making care more accessible.