NYAPRS Note: The lack of parity between commercial insurance and Medicaid affects those who use services as well as the agencies which provide the services. Without true parity, far too many people will be unable to access services and more agencies will be forced to choose between taking on more debt or providing services to those who need them. There is still time for you to urge the Assembly to include Governor Hochul’s Behavioral Health insurance reforms in the budget! Send a letter to your Assembly member today by clicking the link to NAMI’s online letter writing campaign here:
Health care groups push NY to fix payment rate disparities for behavioral health providers
Crain’s New York | March 27, 2023
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Jeffrey Reynolds, chief executive of the Family and Children’s Association in Nassau County, says the two outpatient behavioral health clinics his organization runs operate like night and day.
At one, in Hempstead, things are going smoothly. At the other, in Hicksville, some patients seeking behavioral health treatment are thousands of dollars in debt—and the clinic is left with gaping financial holes it can’t patch.
The difference between the two clinics is simple: The Hempstead location sees about 11% commercially insured patients, with the rest insured by Medicaid and Medicaid managed care. At the Hicksville location, 36% of patients have commercial insurance, Reynolds said.
New York state sets Medicaid payment rates to behavioral health care providers. But providers have to negotiate rates with commercial insurers. As a result, commercial insurers pay on average 50% less than Medicaid pays, said Lauri Cole, executive director of the New York State Council for Community Behavioral Healthcare. This makes it so that providers have a harder time accepting commercially insured patients and creates an access barrier for New Yorkers who need behavioral health treatment.
This trend is in contrast to what is typically seen at New York’s hospitals, where Medicaid reimbursement rates are usually lower than commercial rates and facilities with a high percentage of Medicaid patients are more prone to financial struggles.
Gov. Kathy Hochul’s proposed budget includes bids to address this disparity, including legislation that would require state-regulated insurers to cover and reimburse the cost of behavioral health services, including medications for substance use disorder, telehealth services and services for New Yorkers with developmental disabilities.
While the state Senate’s part of the legislative one-house resolution includes those proposals, Cole expressed concern over Assembly’s portion, which omits them.
In the lead-up to the Legislature’s vote on the budget, the Council for Community Behavioral Healthcare, which consists of more than 100 provider members across the state, is pushing legislators to include measures to address the pay difference in New York’s final budget.
These pay differences, Reynolds said, become very visible at the Hicksville clinic when commercially insured patients with $75 co-pays need treatment three times per week. They often can’t afford those co-pays or the cost of treatment and wind up in debt for as much as $10,000, he said. But because the Family and Children’s Association is committed to seeing all patients regardless of their ability, the facility just keeps operating at an enormous loss, he explained.
Facilities that operate in this manner are in danger of shutting down, Reynolds added, which would create a care and access gap for many patients who need this kind of care.
Ann Marie Foster, chief executive of Phoenix House. which provides behavioral health care at nine locations from Brooklyn to the east end of Long Island, referred to commercial insurance rate negotiations as “the Wild Wild West.”
“This is something that a lot of the providers have been fighting for well over a decade,” she said. “I think it speaks to stigma and the barrier to access to treatment.”
While the majority of Phoenix House patients are covered by Medicaid or managed care, the organization often can’t accept a wide range of commercial insurance, Foster said. Patients that need care don’t come to Phoenix because it’s not on the list of places where they would be covered, she said.
Care access is particularly vital in the wake of the pandemic, when more New Yorkers than ever are contending with mental health concerns, Foster said.
Cole, of the state Council for Community Behavioral Health, added that widening access is particularly important for young New Yorkers.
“[Crisis] prevention is critical. Early identification screening assessment is critical. And when that doesn’t happen, [diseases] are allowed to linger and grow,” she said. “The spend on early intervention isn’t nearly what it will be if that young person grows up to have a full-blown mental health crisis or mental illness that goes unchecked.”
Improving network adequacy, or a health plan’s ability to deliver care by promising reasonable access to enough physicians and services, is crucial, Cole said. Her organization has been pushing the state to update its rules around adequacy.
Jeffrey Brenner, chief executive of health and human services agency the Jewish Board, said some commercial insurers try to justify their rates by saying they pay more than Medicaid for certain services.
But the services they pay more for, such as family group therapy sessions, only account for a small percentage of the care the Jewish Board provides, Brenner said. The vast majority of services, including 30-minute and 45-minute psychotherapy sessions and routine psychiatry treatments, are underpaid by commercial insurers, he said.
As New York approaches the April 1 budget vote deadline, Brenner said, the Jewish Board and other providers and associations will lobby to ensure rate provisions are in the final budget. But organizations such as the Jewish Board have less lobbying strength than large, powerful hospitals, he said.
“What we’re going to be doing between now and the end of the session,” Cole said, “is pushing like crazy for all of the insurance proposals to be supported and enacted. We’re having meetings every day, all day, with Assembly and Senate central staff. We cannot wait till the second half of the session to implement these proposals.”