The New York State Department of Financial Services (DFS) and the Department of Health (DOH) have recently adopted ‘network adequacy’ regulations requiring health plans to enhance access to mental health and substance use disorder services. Importantly, the DFS regulation applies to fully insured health insurance plans written in New York (while the mirrored DOH regulations apply to HMOs, including Medicaid managed care plans). These ‘network adequacy’ regulations do not apply to self-funded plans or fully insured plans issued outside of New York.
The new regulations, which take effect on July 1, 2025, will require a plan to:
- Provide an initial behavioral health appointment within 10 business days of a member’s request, or within seven calendar days following discharge from a hospital or emergency room. If in-network providers are unavailable within these timeframes, the plan must authorize access to an out-of-network provider at the in-network cost-sharing rate;
- Update provider directories with practice locations, provider affiliations, and any restrictions on scope of services; and
- Maintain compliance through an ‘access plan,’ outlining protocols for ensuring behavioral health access and monitoring provider capacity. Written certification of compliance is required by carriers annually, with the first report due by December 31, 2026.
Employer Takeaways
Although the ‘network adequacy’ rules do not require direct employer action, employers should stay informed. Employers sponsoring fully insured group health plans issued in New York may wish to confirm with their carriers that their plans comply with the updated standards for plans issued or renewed on or after July 1, 2025.
Additional Resources
Connect with a Sequoia consultant to learn how Sequoia’s compliance services are integrated in our benefits services and tailored solutions. And if you’re already a Sequoia client, stay on top of your employer obligations with your Compliance Checklist that highlights important compliance dates, action items, and resources.
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