More than $2.6 million in penalties has been levied by New York State against five Medicaid managed care health plans following a comprehensive examination of their reimbursement of behavioral health service claims. These fines are in response to the state’s claim the carriers repeatedly and inappropriately denied claims or failed to pay for specialty behavioral health services at the rates required by law.
The fines resulted from the Health Plan Focused Survey Results for Behavioral Health Claims Denials, a report compiled by the Office of Mental Health. The denials were most frequently for care provided by Assertive Community Treatment; Personalized Recovery Oriented Services; Comprehensive Psychiatric Emergency Program, partial hospitalization; and Adult Behavioral Health Home and Community Based Services.
The companies penalized include:
- Affinity Health Plan, Inc., which was fined $349,500 for failing to provide adequate oversight of delegated management function and failing to reimburse providers at required rates.
- Amida Care, Inc., which was fined $232,000 for inappropriately denying behavioral health claims and failing to comply with prompt pay requirements.
- EmblemHealth, which was fined $422,000 for failing to correct inappropriate claims denials and failing to pay claims at required minimum rates.
- MetroPlus HealthPlan, Inc., which was fined $584,000 for failing to pay claims at required minimum rates; and failing to reimburse providers at the required rates.
- MVP HealthPlan, Inc., which was fined $1 million for failing to pay claims at required minimum rates and failing to reimburse providers at required rates.
The Office of Mental Health monitors managed care organizations on an ongoing basis to ensure they are properly providing behavioral health services to their members. Focused surveys identify issues that may require compliance monitoring and corrective actions.
The agency worked in partnership with the New York State Department of Health to issue the regulatory action. The Health Department has the legal authority to apply fines and enforce compliance in the Medicaid program.
“No New Yorker should face unnecessary barriers to mental health care, especially if their insurance carrier fails to meet their legal obligation to cover these essential services,” Governor Kathy Hochul said. “My administration is committed to holding insurance companies accountable to ensure New Yorkers can access the critical mental and behavioral health care that they need.”
