NYS BH Ombuds Program to Educate and Protect Insurance Rights

NYAPRS Note: New York State has launched a pioneering Ombuds program to help advance and protect the rights of New Yorkers to get full access to behavioral health services that might otherwise be denied to individuals and families seeking to promote their recoveries and, in far too many instances, protect their lives. Great thanks to the Offices of Alcoholism and Substance Abuse Services, the Office of Mental Health and the Department of Financial Services and to the Cuomo Administration for this landmark initiative and to our colleagues at the Legal Action Center, the NYS Council for Community  Behavioral Healthcare and the Community Services for their collaborative efforts to carry it out.

We are thrilled that the Center will be led by Project Director Stephanie Campbell, a long time extraordinary advocate for recovering people from across the state and former executive director of our friends at FOR-NY.

OMH, OASAS and DFS Announce New Program and Regulations to Help New Yorkers Access Insurance Coverage for Substance Abuse and Mental Health Disorders
Behavioral Health Ombudsman Program will Educate Families and Individuals on Their Insurance Rights and Help When They Are Denied Coverage

October 09, 2018

 Three New York State agencies – the Office of Alcoholism and Substance Abuse Services, the Office of Mental Health and the Department of Financial Services -- today announced a new program to help ensure all New Yorkers are able to access their insurance coverage for substance use disorders and mental health services.

 The new Ombudsman Program, called Community Health Access to Addiction and Mental Healthcare Project (CHAMP) will educate individuals, families, and health care providers on their legal rights to coverage, help them to access treatment and services and will investigate and resolve complaints regarding denial of health insurance coverage…..

 The 2018-19 Budget includes $1.5 million to establish the new Ombudsman program in partnership with Community Service Society (CSS), the Legal Action Center and the NYS Council for Community Behavioral Healthcare, organizations with a proven record and a statewide network that has helped individuals, families, and small businesses gain access to affordable, quality health coverage.

 These organizations will help individuals and families navigate the complex health care system to obtain timely access to and/or continue substance use disorder and/or mental health care. They will also help to resolve complaints when care is denied and identify areas where insurers may have an inadequate network of treatment programs and providers.

 The organizations will also work with the Ombudsman’s office and with their partner network, which includes Chambers’ of Commerce, social service organizations and ethnic and immigration advocacy groups, to conduct community outreach, education and presentations on health insurance and New Yorkers’ rights…..

 Stephanie Campbell, former Executive Director of Friends of Recovery – New York, a statewide network for people in recovery, will serve as NYS Ombudsman Project Director and oversee implementation of the program for OASAS and OMH. A general mailbox (Ombuds@oasas.ny.gov) and a hotline number (888-614-5400) have been established for questions about the program.

 Governor Cuomo also issued a proclamation designating October 2018 as MENTAL HEALTH AND ADDICTION PARITY MONTH in New York. The proclamation calls on insurers “…to take immediate steps to demonstrate to regulators that all their practices are in compliance with state and federal parity laws so that New Yorkers can access the mental health and substance use disorder services and medications they need to lead healthy and productive lives.”

 Arlene González-Sánchez, Commissioner of the Office of Alcoholism and Substance Abuse Services (OASAS) said, “This program will help to educate people on their rights, and help them access the treatment and services they need without the stress of having to navigate the complicated insurance system on their own. Ensuring that people with substance use disorders are able to receive these services, regardless of their insurance situation, is a vital part of the support that we can provide for them.”

 Dr. Ann Sullivan, Commissioner of the NYS Office of Mental Health (OMH) said, “About 1 in five New Yorkers require behavioral health services, and often many do not receive treatment because of stigma and other barriers to treatment. This can be a matter of life and death, and the new Behavioral Health Ombudsman Program will help to improve access to insurance coverage for substance use disorder and mental health services.”

 Maria T. Vullo, Superintendent of the NYS Department of Financial Services said, “DFS is steadfast in its commitment to insurance coverage parity for mental health and substance use disorder. Insurers are required to provide coverage for mental health and substance use disorder on par with medical and surgical benefits. DFS is proud to work with all stakeholders to ensure that health insurers comply with parity protections so that New Yorkers in need of services for mental health and substance use disorder receive necessary treatment and are not improperly charged for benefits to which they are entitled.”

 Assemblymember Linda B. Rosenthal, Chair of the Committee on Alcoholism and Drug Abuse, said, “Recovering from substance use disorder is hard enough without trying to navigate the Byzantine bureaucracies and insurance protocols that often make accessing treatment services more difficult. The ombudsman program is a critical resource for families that will hopefully remove many of the administrative barriers to treatment so that people can focus on getting well. I was happy to fight for its inclusion in the 2018 Budget and look forward to seeing it, and similar programs, expanded in the future.”

 Senator Rob Ortt, Chair of the Senate Committee on Mental Health and Developmental Disabilities, said “I am proud to have helped secure a crucial $1.5 million in this year’s budget for the Community Health Access to Addiction and Mental Healthcare Project. As Chair of the Senate Committee on Mental Health and Developmental Disabilities, I know how overwhelming the process can be for families and patients when looking to obtain substance addiction and mental health services. CHAMP will ensure that those who are in need have a guide to help them navigate what can be a complicated issue. By increasing access to these vital services, we are making certain that our residents have the best chance at overcoming their disease.”

 Senator George Amedore, Chair of the Senate Standing Committee on Alcoholism and Substance Abuse, said, "When an individual or loved one is struggling with addiction, navigating the system to get access to treatment can be a difficult, stressful undertaking. This new program ensures that people are informed of their rights when it comes to insurance coverage, and will help them find and access the services they need."

 Glenn Liebman CEO, Mental Health Association in New York State, Inc. (MHANYS) said, “We are very appreciative of Governor Cuomo and the state agencies involved for their continued commitment to ensuring that all New Yorkers can access insurance coverage for substance use disorders and mental health care. The new Ombudsman program will help consumers better understand their rights and help them to receive the behavioral health treatment they need.”

 Lauri Cole, Executive Director of the New York State Council for Community Behavioral Healthcare said, "New York's first independent Behavioral Health Ombuds Initiative provides a critical opportunity to assist New Yorkers who are struggling to access or continue care they are entitled to. Too many New Yorkers are denied substance use disorder/addiction or mental health care, have seen their care curtailed prematurely, or have just given up due to frustrations experienced while trying to access their benefits or understand their rights. We are honored to be involved in this important Initiative that we know will save many lives."

 Elisabeth Benjamin, Vice President of Health Initiatives at the Community Service Society, said, “CSS is delighted and proud to be able to work with New York State to offer this valuable advocacy service for New Yorkers in need of substance use disorder and mental health care. This program will help both consumers and providers break down barriers and improve access to life-saving care.”

 Sebastian Solomon, Director of NYS Policy for the Legal Action Center, said, “This ombuds program is a critically important resource that will help countless New Yorkers and their families to obtain the substance use and mental health services they need and are entitled to under the law and their insurance policies. The Legal Action Center is honored to work with OMH, OASAS, the Community Service Society, and the Council of Behavioral Health Agencies to help increase access to affordable, quality treatment for New Yorkers seeking behavioral healthcare services."
Partnering with Community-Based Organizations.


 DFS Issues New Regulations

The Department of Financial Services also recently implemented a new regulation that requires 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 the new 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. Insurers must also 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.

 To ensure that individuals impacted by the opioid epidemic receive swift access to appropriate treatment, DFS has also advised insurers that, under New York Insurance Law, they are:

  • Prohibited from requiring preauthorization for outpatient substance use disorder treatment in facilities that are certified by the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and participate in the insurer’s provider network;
    Prohibited from performing concurrent utilization review, a process for determining coverage while a person receives treatment, during the first two weeks of continuous outpatient substance abuse disorder treatment in facilities that are certified by OASAS and participate in the insurer’s provider network provided the facility notifies the insurer of both the admission and the initial treatment plan within 48 hours of the start of treatment;
    Prohibited from requiring preauthorization for inpatient SUD treatment in facilities that are certified by OASAS and participate in the insurer’s provider network; and
    Prohibited from performing concurrent utilization review in facilities that are certified by OASAS and participate in the insurer’s provider network during the first 14 days of an inpatient admission provided the facility notifies the insurer of both the admission and the initial treatment plan within 48 hours of the admission.
    These provisions apply to medication-assisted treatment performed as outpatient services at facilities that are certified by OASAS and participate in the insurer’s provider network.

 10 Year Anniversary of Federal Parity Legislation

The new Behavioral Health Ombudsman program and other reforms underway for parity enforcement come on the tenth anniversary of the 2008 Federal Mental Health Parity and Addiction Equality Act (MHPAEA) which requires commercial insurers to apply the same standards for access to mental health and addiction treatment services compared to medical and surgical care.

 New York has been a leader in advancing parity 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. However, national studies continue to reveal significant challenges with accessing behavioral health services and individuals and families with comprehensive health insurance coverage experience higher out-of-network use, lower reimbursement and restrictions on coverage for needed behavioral health services including mental health counseling and treatment for addiction.