In addition to the payment, the insurer must pay restitution to consumers, expand its mental health network, and submit to independent monitoring.
New York Attorney General Letitia James and EmblemHealth have reached a multi-million dollar settlement following a state investigation that found the insurer repeatedly failed to provide members with accurate information about mental health providers, leading to many unable to access timely, affordable care.
EmblemHealth serves approximately 1.5 million New Yorkers across commercial, Medicaid, Child Health Plus, Essential Plan, and New York City employee plans.
The Office of the Attorney General (OAG) determined that EmblemHealth overstated the availability of in‑network mental health and substance use disorder providers and maintained widespread inaccuracies in its provider directory. In a secret shopper survey, the OAG found that more than 80 percent of behavioral health providers listed as accepting new patients were effectively unavailable, which created “ghost networks” that misled members seeking appointments.
James said the company’s failures came at a time when millions of New Yorkers are struggling with mental health challenges. “Health insurers cannot mislead consumers with inaccurate provider directories while families are left without care,” she said in an announcement.
Under the agreement, EmblemHealth will pay penalties and fees and establish a restitution process for members who paid out‑of‑pocket for mental health services after being unable to secure appointments with in‑network providers.
Reforms to improve access to care
The company must also implement a comprehensive set of reforms to improve access, including:
- Correct inaccurate listings within two business days.
- Add a link next to every provider listing allowing inaccuracies to be reported.
- Require providers to verify directory information every 90 days.
- Remove providers who have not submitted a claim within 90 days unless they confirm continued participation.
- Create enhanced systems to track and resolve directory‑related complaints.
- Conduct regular secret shopper surveys and publicly report results.
If inaccurate directory information causes a member to inadvertently see an out‑of‑network provider, EmblemHealth must ensure the member pays no more than their normal in‑network copay or deductible.
EmblemHealth also must meet new standards guaranteeing timely access to mental health services, including:
- 24 hours for urgent appointments
- 10 business days for initial outpatient visits
If members cannot obtain timely in‑network care, the insurer must allow them to see out‑of‑network providers at in‑network cost‑sharing levels. EmblemHealth is also required to develop a statewide recruitment and retention plan to expand its behavioral health network.
An independent monitor will oversee both the restitution program and the company’s compliance with the mandated reforms.
The settlement is part of a broader effort by James to crack down on mental health ghost networks across the state. In the last two years, her office has taken action against multiple insurers and health systems for similar failures, including MVP Health, WMCHealth, and the Trump administration over youth mental health funding.