About one in five New Yorkers require behavioral health services, but many do not receive treatment because of a lack of access to insurance coverage. More than 10 years ago, the federal Mental Health Parity and Addiction Equity Act required large group health plans that provide mental health coverage to do so at levels comparable with medical services.
And yet national studies continue to reveal significant challenges with accessing behavioral health services for individuals and families even if they have comprehensive health insurance coverage. Individuals and families often experience higher out-of-network use, lower reimbursement and restrictions on coverage for needed behavioral health services including mental health services and treatment for addiction.
Fortunately, Governor Andrew Cuomo included critical parity and insurance reforms in his 2019 Justice Agenda, and these new laws and regulations will help guarantee access to mental health care for all New Yorkers. These laws require that insurers apply the same standards for access to mental health and addiction treatment services as they do to medical and surgical care. Some of the strongest and most effective in the nation, these laws will offer additional protections to individuals in need of mental health services and will provide them with help if they feel these laws are not being followed. We now have a clear blueprint to ensure real parity!
Community Health Access to Addiction and Mental Healthcare Project (CHAMP)
In order to help all New Yorkers access insurance coverage for substance use disorders and mental health services, Governor Cuomo and members of the State Legislature created the Community Health Access to Addiction and Mental Healthcare Project (CHAMP).
CHAMP, an ombudsman program developed in partnership with the Community Service Society, the New York State Council for Community Behavioral Healthcare, The Legal Aid Society, the Medicare Rights Center, and the Legal Action Center, will assist individuals and families in obtaining their legal rights to insurance coverage, helping them to access treatment and services, and resolving complaints regarding denial of health insurance coverage.
The program can help participants by: Listening to their concerns and complaints; Educating participants about their insurance rights; Empowering participants to advocate for themselves and work successfully with treatment providers to address insurance concerns; Helping to address barriers to treatment they need, including medication; and Getting the most from their insurance coverage for substance use disorder and mental health services.
Helpline representatives may be able to resolve concerns immediately, or will enlist the expertise of dedicated CHAMP legal, substance use disorder, or mental health specialists to address the issue. Participants can be assured of timely, respectful, and culturally sensitive assistance with concerns regarding: Access to treatment; Denial of services; Access to medication; Parity/coverage discrimination issues; System navigation; Medical benefits; Enrollment referral; and Legal assistance for insurance appeals.
Consumers and providers can get help from CHAMP by calling the new helpline number (888-614-5400) or by writing to ombuds@oasas.ny.gov.
Additional New Parity Laws and Regulations
Under Governor Cuomo’s leadership, New York has enacted additional tough new laws and regulations that will: Prohibit prior authorization for minors entering inpatient psychiatric treatment and prohibit concurrent utilization review during the initial 14 days of treatment; Prohibit insurers from requiring prior authorization to receive medication-assisted treatment (MAT) for substance use disorders (SUDs) and extending the time period for concurrent review for inpatient and outpatient addiction treatment; Require insurers’ medical necessity criteria for mental health services be reviewed and approved by the Office of Mental Health; Limit patient co-payments for outpatient mental health services and SUD treatment to the equivalent cost of a primary care visit and limiting co-payments for outpatient SUD treatment to one per day; Require network adequacy that provides for timely access to providers; and Codify key parity standards in State law for both MH and SUD benefits.
Governor Cuomo also signed the Mental Health and Substance Use Disorder Parity Reporting Act (Chapter 455; Laws of 2018), which requires health plans to submit key data to the Department of Financial Services (DFS) to ensure compliance with State and Federal Parity Laws. DFS will post this information on its public website, allowing consumers and healthcare providers to determine how well insurers comply with the Parity Act.
This builds upon last year’s implementation by DFS of a new regulation that required insurers to include in their policies a process for insureds, their designees or prescribers to request a review of a decision that a medication for detoxification or maintenance treatment of a substance use disorder drug is not covered by the policy.
Under that regulation, every insurer that provides hospital, surgical, or medical expense coverage and also provides coverage for medication for the detoxification or maintenance treatment of a substance use disorder must include in the policy processes that allow an insured, the insured’s designee, or the insured’s prescribing physician to request a formulary exception and gain access to clinically appropriate medication for the detoxification or maintenance treatment of a substance use disorder not otherwise covered by the policy.
Insurers must make determinations on standard exception requests and notify the insured, or the insured’s designee, and the insured’s prescriber no later than 72 hours after the request. It also required insurers to have a process for expedited formulary exception requests based on exigent circumstances and make determination and notification no later than 24 hours after such requests.
New York has been a leader in advancing parity during the past decade, with early passage of Timothy’s Law, protections for the integration of behavioral health services into Medicaid managed care and reforms to address the opioid epidemic. This package of new laws will help to improve access to insurance coverage for substance use disorder and mental health services and will help eliminate barriers, increase accountability among insurers and health plans, and ensure that New Yorkers receive all the benefits they are entitled to.
