The New York Attorney General (AG) website, AG Eric T. Schneiderman announced a settlement with New York’s EmblemHealth, Inc., demanding the insurer to comply with parity laws. AG Schneiderman is requiring the company to reform their behavioral health appeals review process and to submit previously denied mental health and substance abuse treatment claims for independent review following. After investigating EmblemHealth and Value Options, the AG’s Health Care Bureau found the managed behavioral organization had denied more than 64% of appeals in comparison to medical cases. “Our mental health parity laws were enacted to ensure that New Yorkers have adequate access to mental health and substance abuse treatment,” Attorney General Schneiderman said. NY’s parity law (Timothy’s Law) was enacted in New York to make sure insurers provide mental health coverage at least equal to coverage provided for other health conditions. This law is similar to the federal Mental Health Parity and Addiction Equity Act which prohibits health plans from imposing greater financial requirements or treatment limitations on mental health or substance use disorder benefits than on medical or surgical benefits.
EmblemHealth has agreed to provide members with an independent review of claims or requests that were previous denied from 2011 and to reimburse members that were denied residential treatment costs. Back tracking costs could mean more than $31 million in reimbursement to more than 15,000 members.
EmblemHealth has agreed on making the following changes:
- Removing visit limits for almost all behavioral health services
- Classifying claims correctly so that members are afforded full appeal rights
- Removing the requirement that members “fail” outpatient services to receive inpatient rehabilitation
- Basing number of treatment days or visits approved on members’ needs rather than arbitrary limits
- Integrating medical and behavioral health claims review, which will facilitate the coordination of members’ care
- Ensuring that denial letters are accurate and specific
- Continuing coverage of treatment pending completion of appeals
- Charge members lower, primary care co-payment for outpatient visits
- Appoint full-time behavioral health advocates to assist members
Consumers who have questions or concerns in reference to this settlement may call the AG’s Health Care Bureau Helpline at 1-800-428-9071.
Maryland Parity Project is excited to see state AG’s taking a proactive role in MHPAEA enforcement. We hope this trend will continue in other states. Feel free to contact the Maryland Parity Project with your parity issues and we will be more than happy to assist you.