Five Medicaid managed care plans to pay fines to state

Five insurance companies have been fined more than $2.6 million by the state for denying claims or failing to pay for specialty behavioral health services at the rates required by law.

Gov. Kathy Hochul announced the penalties against the five Medicaid managed care health plans following a comprehensive examination of their reimbursement of behavioral health service claims in a media release.

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 release said. 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 are:

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, the release said. Focused surveys identify issues that may require compliance monitoring and corrective actions.

The agency worked in partnership with the state Department of Health to issue the regulatory action, the release said. The Health Department has the legal authority to apply fines and enforce compliance in the Medicaid program.

Legislation adopted as part of the FY 2024 State Budget prohibits commercial insurance plans from denying coverage for medically necessary inpatient services, including life-saving care coordination services, the release said. Commercial plans are also now required to adopt appointment availability and geographic accessibility standards for behavioral health services, and to cover all services provided by school-based mental health clinics. In addition, Governor Hochul secured legislation requiring providers to pay at least the Medicaid reimbursement rate for care provided at these clinics.