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Essential Plan and Behavioral Health Services
Can I access mental health and substance use disorder
services with the Essential Plan?
If you receive health insurance coverage through the Essential Plan, you
should be able to access mental health and substance use disorder
services through your coverage. If you are enrolled in a managed care
plan, you can contact your health plan or its Member Services division to
learn more about your coverage for these services. If you need a list of
the health plans that participate in the Essential Plan in New York, you
can consult the NY State of Health Essential Plans for 2022. A list of plans
that have participated in the Essential Plan in New York during 2020 and
2021 is also available through the New York State of Health.
New York State and federal laws require most comprehensive health
insurance plans to cover medically necessary mental health services and
manage your mental health or substance use benefits as they manage
medical and surgical benefits, without additional limitations. This is
called “mental health parity” and requires that rules about copayments,
number of visits and pre-authorizations should be similar for accessing
mental health and substance use disorder services as they are for
physical medical care. The NYS Office of Mental Health provides more
information on mental health parity for New Yorkers.
What type of mental health and substance disorder services
can I get with the Essential Plan?
Your managed care plan should provide you with a Summary of Benefits
and Coverage (SBC) in clear and accessible language that describes
what is covered under your specific health plan. An example of the SBC
is available on healthcare.gov. The SBC will show you the costs and
services associated with your health plan, including information about
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mental health and substance use disorder services in a section titled
“Types of Medical Events”. You can learn more about the SBC on
healthcare.gov.
If you do not have your SBC, you can request it from your health plan
using the phone number provided on the back of your health insurance
card or you can call 1-800-698-4KIDS (1-800-698-4543) to get more
information about how to get your SBC.
In June 2021, New York eliminated monthly premiums and added free
dental and vision for those enrolled in the Essential Plan. Prior to June
2021, Essential Plan enrollees with incomes between 150 % of the
Federal Poverty Level (FPL) ($19,230 annually for an individual) and 200%
FPL ($25,760 annually for an individual) had a $20 monthly premium.
You can also consult this 2022 Essential Plan Benefit & Cost Sharing Chart
to see, generally, what you might expect to pay for different covered
services.
New York’s managed care plans that offer Essential Plan coverage must
also cover prevention services that can help people address behavioral
health issues, such as unhealthy alcohol use screening and counseling or
depression screening, which can support health and wellbeing. You can
find a for a list of preventive services that must be covered by managed
care plans offering the Essential Plan at healthcare.gov.
Will I need a referral or prior authorization to get mental
health and substance use disorder services through Child
Health Plus?
Depending on your particular health plan, you may need to get prior
authorization or a referral from your primary care doctor before you can
receive the mental health or substance use disorder services you might
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need. You should check your SBC or contact your health plan to confirm
whether a referral or prior authorization is required.
If you don’t need a referral from your primary care provider, you can use
the NYC Well website to find a mental health professional. Visit NYC Well
or call the NYC Well Hotline at 1-888-NYC-WELL (1-888-692-9355) and
indicate that you need to find a mental health provider who accepts the
Essential Plan.
Additional Resources Regarding Mental Health and
Substance Use Disorder Services
If you need help finding a mental or behavioral health
provider
Call 1-888-NYC-WELL (1-888-692-9355) or visit NYC Well Find Services
If you want to learn more about the Essential Plan and its
benefits:
Call the New York State of Health at 1-855-355-5777 or TTY at 1-800-
662-1222 or visit NYS Department of Health Child Health Plus
Visit NYC Health Insurance Link
Download Essential Plan Fact Sheet
Download Essential Plan Map
Download Essential Plan at a Glance
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If you have been denied mental health services
Depending on your insurance, you may be protected by Mental Health
and Addiction Insurance “Parity” law.
Health plan members are also entitled to request and receive a copy of
the most recent comparative analysis performed by their health
insurance plan to assess compliance with federal parity laws and
regulations. If your health insurance plan refuses to provide this
information to you, you can call the Consumer Assistance Unit of the NYS
Department of Financial Services at 1-800-342-3736 to get assistance.
The New York State Office of Mental Health (OMH) provides additional
information about mental health parity.
If you need help navigating the health care system
Contact Community Health Advocates (CHA), a program of the
Community Service Society, for free help on how you access the health
care you need. You can call the CHA Helpline at 1-888-614-5400.
Important Note: This information is compiled from government
handbooks and webpages and relies on them for accuracy and is current
as of December 17, 2021. It is provided here for your assistance and
should not be taken as legal advice.
