Carelon will pay more than $10 million across two settlements in New York over mental health networks and coverage denials.
The company, a division of Elevance Health, will pay $2.35 million in penalties, fees and costs as well as up to $8 million in restitution for members who paid out-of-pocket for out-of-network mental healthcare, to reimburse those whose claims were improperly denied or to overhaul its networks.
New York Attorney General Letitia James said in an announcement that the settlements resolve two investigations from her office that determined the company misled members by directing them to seek care from providers that were out-of-network—through so-called "ghost networks"—and improperly denied coverage for treatment for substance abuse disorder.
James noted that Carelon administers behavioral health benefits for multiple plans, including Anthem Blue Cross, EmblemHealth, Independent Health and the Empire Plan, which covers state and local government workers.
Across these insurers, Carelon manages behavioral health benefits for more than 4 million people in the state, James said.
The alleged behavior also goes against a 2015 agreement with the AG's office, where the company agreed that it would maintain accurate provider networks and "use approved criteria" when denying substance abuse treatments.
"When someone is ready to seek help for a mental health condition or addiction, every day matters," said James. “Carelon left New Yorkers calling provider after provider who could not see them and made it harder for people to get the treatment to which they were entitled."
"These settlements will help people get the care they need and put money back in New Yorkers’ pockets," she said.
Elevance Health had not responded to a request for comment at the time of publication.
Carelon was hit with a lawsuit in April over the alleged ghost networks and their impact on the Empire Plan in particular. In the case, plaintiff's attorneys conducted secret shopper calls to analyze Carelon's network, calling 300 providers. Just 17% of those contacted took insurance and were open to new patients.
These "ghost networks" have also drawn concern in other markets, such as for maternal care services in Medicaid and in Medicare Advantage. A study released last month found that commercial plans also routinely have inaccurate provider directories.