(WRGB) — New York Attorney General Letitia James announced a sweeping settlement with EmblemHealth that will require the insurer to pay more than $2.5 million and implement major reforms after an investigation found widespread barriers preventing members from accessing mental health care.
According to the Office of the New York State Attorney General, the probe revealed EmblemHealth maintained inaccurate provider directories and overstated the availability of in-network mental health and substance use disorder providers. Investigators said many listed providers were unreachable, not accepting new patients, no longer practicing, or not actually part of the insurer’s network, creating so-called “ghost networks” that existed on paper but not in reality.
Attorney General James,
As millions of New Yorkers struggle with anxiety, depression, and substance use disorders, ensuring access to quality, affordable mental health care is more essential than ever. Health insurers cannot mislead consumers with inaccurate provider directories while families are left without care. We are requiring Emblem to make meaningful changes so that New Yorkers can actually access the behavioral health treatment their insurance promises.
A secret shopper survey conducted during the investigation found that more than 80% of behavioral health providers listed as accepting new patients were effectively unavailable. The attorney general’s office said these issues left many New Yorkers unable to obtain timely or affordable care.
Under the settlement, EmblemHealth will pay $2.5 million in penalties, fees, and costs, and establish a restitution program for members who were forced to pay out of pocket because they could not secure appointments with in-network providers. The company must also implement significant operational changes, including:
- Correcting inaccurate directory listings within two business days
- Adding reporting links so members and providers can flag errors
- Requiring providers to verify information every 90 days
- Removing providers who fail to verify participation or who appear inactive
- Conducting regular secret shopper surveys and publicly reporting results
The insurer must also meet appointment access standards, including offering urgent mental health care within 24 hours and initial outpatient appointments within 10 business days. If an in-network appointment cannot be secured within those time frames, members must be allowed to see out-of-network providers while paying only their in-network cost-sharing amount.
In addition, EmblemHealth must create a recruitment and retention plan to expand its behavioral health network statewide. An independent monitor will oversee both the restitution process and compliance with the reforms.
James said the action is part of her office’s broader effort to combat mental health “ghost networks” and ensure insurers provide the coverage they promise.
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