Managed Care Reports

Reports on health plan performance are designed to help you choose a health plan that meets your needs and the needs of your family. The reports provide easy-to-read information on health plan performance with respect to primary and preventive health care, access to health care, behavioral health and enrollee satisfaction. Data is provided for commercial and government-sponsored managed care. Enrollment reports show the level of consumer participation in various types of managed care plans.

*Portable Document Format (PDF)

Managed Care Organization Focused Survey Citations

Focused Survey Overview:

The Department of Health monitors MCOs on an ongoing basis for compliance with Public Health Law Articles 44 and 49, 10 NYCRR Part 98, the Medicaid Model Contract for those plans offering Medicaid, and other State and federal laws and regulations as applicable. As part of its MCO oversight activities, the Department conducts focused surveys which identify specific issues requiring compliance monitoring and correction if needed. When the Department finds through a focused survey that a MCO is not complying, it issues a citation to the MCO. A citation may be a Statement of Deficiency (SOD) for failure to comply with law or regulation or a Statement of Finding (SOF) for failure to comply with the Medicaid Model Contract.

Once a citation is issued as a result of a focused survey, the MCO is given an opportunity to review and respond with a plan to correct the non-compliance. Once this plan is accepted by the Department, the citation and corrective action is final and is published on this website.

Mental Health Parity and Addiction Equity Act (MHPAEA) Focused Surveys (2018-present)

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires that generally coverage for mental health/substance use disorders (MH/SUD) cannot be more restrictive or more expensive than medical/surgical coverage. (For more information on MHPAEA, please click here.) MCOs are required to perform self-assessments of their payment and approval practices and report the results to the State. The focused survey reviewed MCO reporting documentation and issued citations to MCOs who did not provide adequate documentation to conduct the review. The citations and accepted corrective actions are located here.

Behavioral Health Claims Denial Root Cause Analysis Focused Surveys (2017-present)

Focused surveys were initiated to examine MCO behavioral health prior authorization and claims adjudication processes. It was determined that there was a high rate of improper denials for some MCOs who delegated prior authorization and claims adjudication of behavioral health services to a third-party vendor. The non-compliant MCOs were issued citations for failure to properly oversee their vendor, inappropriately denying claims for no prior authorization when prior authorization was not required and failure to pay BH claims correctly and timely. The citations and accepted corrective actions are located here.

Key Staffing Focus Surveys (October, 2021 to present)

MCOs are required to provide written notice to the State when there are changes in key staff at the MCO for behavioral health services. The notice shall include the name of an interim contact person, plan for replacing the key person, and an expected timeframe for replacement.  The State issued a reminder to MCOs of this requirement. Several plans failed to provide the State with the required notification when key staff left the MCO. As a result, the non-compliant plans were issued a citation. The citations and accepted plan of corrections are located here.

Behavioral Health Network Adequacy

In partnership with the NYS DOH, NYS OMH reviewed PNDS reports for four consecutive quarters and identified services where MCOs failed to meet the required minimum behavioral health network standards. The citations and accepted plan of corrections are located here.

OMH Outpatient Services: Government Rate Compliance

In partnership with the NYS DOH, NYS OMH reviewed Medicaid Managed Care Plan (MMCP) reported service delivery data and subsequent documentation to determine if MCOs are paying the required government rates for behavioral health services. The citations and accepted plan of corrections are located here.

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2025

Archived Reports

This Report serves as New York's parity compliance documentation in accordance with 42 CFR Parts 438, 440 & 457 for benefit packages with members enrolled in Medicaid Managed Care, Alternative Benefit Plan and Children's Health Insurance Program products. The findings contained in the Report stand as the first phase of robust parity monitoring and enforcement workplan for all health insurance products that the State is undertaking.

The Behavioral Health Expenditure Target (BHET) issued on a State Fiscal Year (SFY) basis by the Office of Mental Health (OMH) and Office of Addiction Services and Supports (OASAS), in consultation with the Department of Health (DOH), assess behavioral health spending in Managed Care.

A summary of the BHET calculation methodology as well as definition of terms can be found here.

BHET Report Summary by Line of Business

The Medical Loss Ratio (MLR) is set up to assist the New York State Department of Health (DOH) to ensure that each Managed Care Organization (MCO) calculates and reports a MLR in accordance with 42 CFR Part 438. For a summary of the MLR calculation and definition of terms go here.

MC MLR Report Summary by Line of Business

CMS regulations at 42 CFR § 438.66(e) require states to submit a Managed Care Program Annual Report (MCPAR). The annual report is part of CMS's overall strategy to improve access to services by supporting Federal and state access monitoring for Medicaid beneficiaries within a managed care delivery system.

CMS regulations at 42 CFR § 438.207(d) require that states:

  • Submit an assurance of compliance to CMS that each MCO, PIHP, and PAHP meets the state's requirement for availability of services; and
  • Include documentation of an analysis that supports the assurance of the adequacy of the network for each contracted MCO, PIHP, or PAHP related to its provider network.