Coronavirus (COVID-19)

Information for Insurers and Providers on Coverage for Mental Health Services for Essential Workers

Is the regulation (11 NYCRR 52.16(r)) that waives cost-sharing for in-network outpatient mental health services for essential workers only limited to office visits?
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No, the regulation applies to all outpatient mental health services when provided by an in-network provider.

Does the waiver of cost-sharing apply to prescription drugs to treat mental health conditions?
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No, the regulation does not extend to prescription drugs.

Are partial hospitalization and intensive outpatient treatment services considered to be outpatient mental health services?
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Yes.

When is the regulation effective?
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The regulation became effective on May 2, 2020 and applies to any outpatient mental health service provided on or after that date, even if a course of treatment began prior to that date.

Which insurers does the regulation apply to?
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The regulation applies to insurers, Article 43 corporations, HMOs, and student health plans with a certificate of authority pursuant to Insurance Law section 1124, providing comprehensive coverage for hospital, surgical or medical care.

Does the waiver of cost-sharing apply to the Essential Plan, Child Health Plus, and Medicaid Managed Care Plans?
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The Department of Health is applying the waiver of cost-sharing to the Essential Plan to the extent that the Essential Plan is subject to cost-sharing. Child Health Plus and Medicaid Managed Care Plans do not impose cost-sharing.

Does the regulation apply to Medicare plans (including Medicare Advantage)?
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No, the regulation does not apply to Medicare plans (including Medicare Advantage). Insurers should consult the Centers for Medicare and Medicaid Services for applicable rules.

If an insured was an essential worker as of March 7, 2020, but is no longer an essential worker, does the regulation apply?
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Yes, the regulation applies to all individuals who are, or were, essential workers during the state of emergency declared by Governor Cuomo on March 7, 2020.

What notification are insurers required to send to their providers?
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The regulation requires that insurers provide written notification, which may include e-mail, to its in-network outpatient mental health providers that they shall not collect any deductible, copayment, or coinsurance from an essential worker in accordance with this subdivision. The notification must include the definition of essential worker and include the list of those essential workers that is set forth in the regulation.

How will the provider know that a person is an essential worker?
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Insurers should advise their in-network providers that, prior to collecting any cost-sharing, the provider should ask the individual whether they are or were employed as an essential worker at any time during the state of emergency that was declared on March 7, 2020, using the list of essential workers provided in the insurer’s notice.

The regulation requires cost-sharing to be waived for outpatient mental health services for essential workers. If the cost-sharing is waived, who is responsible for paying for that?
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The regulation requires that no essential worker shall be required to pay for cost-sharing for in-network outpatient mental health services, however the issuer is still responsible for reimbursing the provider for the cost-sharing amount.

What is the insurer’s responsibility to the insured if a provider improperly collects a deductible, copayment, or coinsurance from an essential worker?
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If an essential worker contacts an insurer indicating that a provider improperly collected a deductible, copayment, or coinsurance from them, the insurer should provide a refund or credit to the insured for the amount collected.

Are the provisions of the prompt pay law applicable to claims that involve a waiver of cost-sharing?
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Yes, insurers are still subject to the requirements of Insurance Law § 3224-a, including the timeframes contained therein related to payment of claims.