New York’s Network Adequacy Regulations
This guide will provide basic information about New York State’s Network Adequacy Wait Time Regulations.
If you or someone you know has questions about how health insurance works for mental health or substance use disorder treatment call the free CHAMP helpline at 888-614-5400
What is Network Adequacy?
Most health insurance plans contract with providers to accept their insurance. These providers are “in-network.”
For a network to be adequate it must have enough providers available so that you can get care you need without a long wait or long distance to travel.
What laws does New York have about network adequacy?
In 2025, New York created regulations that limit wait times for an outpatient appointment for substance use disorder or mental health treatment. If a health insurance plan’s network cannot meet these requirements, then the regulation gives you the right to see an out-of-network provider at your health plan’s in-network cost.
This means you would pay your regular co-pay, co-insurance, and deductible even if the provider does not accept your insurance.
However, you must follow specific steps for this regulation’s protections to be effective.
Does the rule apply to all insurance plans?
No. The regulation only applies to health insurance plans regulated by New York State.
These include:
- Medicaid Managed Care
- The Essential Plan
- Child Health Plus
- Managed Long Term Care Plans
- Fully Insured Employer Health Plans
- Other Commercial Health Plans like those bought on the New York State of Health Marketplace
- NYSHIP
- Municipal Cooperative Health Benefit Plans
If you are not sure which health insurance plan you have, CHAMP can help you figure it out.
What are the wait time standards?
Your health plan’s network must be able to offer an appointment for the type of outpatient mental health or substance use treatment covered under your health insurance plan that you need within the following timeframes:
10 business days for an initial outpatient appointment.
7 calendar days for an initial outpatient appointment after being discharged from a hospital or released from an emergency room.
Medicaid Managed Care plans may be required to provide you with quicker access to mental health and substance use disorder care than the timeframes above.
Contact CHAMP for more information.
How do I find a provider that accepts my insurance?
You can look on your health insurance plan’s website or call your plan directly.
Health plans are required to correctly list all their network providers along with the services they offer in a provider directory on their website.
Health plans must have a designated staff available by phone that specialize in mental health and substance use disorder to help enrollees find providers in their network. The contact information for this staff should be in a publicly accessible area of the plan’s website.
Health plans may give you a list of multiple providers in their network that could treat your conditions when you ask. They must do this within 3 business days of your request.
If you find a provider on the list, you should confirm with them that they take your insurance.
If none of the listed providers have appointments within the time standards, you, a family member, friend, or care manager can file an access complaint with your health insurance plan.
What is an Access Complaint?
When you cannot find an in-network provider who can treat your condition within the required wait times, you can file an access complaint with your health insurance plan by telephone or in writing.
Your plan will have 3 business days to locate an in-network provider that can treat your condition and is able to meet the appointment wait time requirements.
The health plan must give you the name and contact information for the provider in writing. If you filed the access complaint by telephone, the health plan must also notify you by telephone.
IMPORTANT:
If you want to meet with a provider in person, you must tell your health insurance plan!
If you do not, your health insurance plan may meet the standards by referring you to a telehealth provider.
What if my plan cannot find me an appointment?
If your health insurance plan cannot find you an appointment that meets the wait time standards then they must let you know within 3 business days of your filing an access complaint.
Your health plan must tell you in writing that you may seek a referral to an out-of-network provider that can meet the wait time standards at the same cost of seeing an in-network provider. If you filed your access complaint by telephone, the health plan must also notify you by telephone.
Before seeing the out-of-network provider, it is important you file an Out-of-Network Referral Request with your health insurance plan.
Your health plan must tell you how to request an Out-of-Network Referral.
Can I go to any out-of-network provider?
No.
The provider must be able to treat your condition and an appointment with them must be available within the wait time standards. The provider must not charge “unreasonable or excessive” fees. Finally, you must get approval from your plan to see the out-of-network provider for treatment.
What can I do if my health insurer doesn’t follow these regulations?
If at any point of the access complaint process your health insurance plan does not follow the regulations, you have the right to file a complaint with the state agency that oversees your health plan.
For employer, union, and commercial plans, you can file a complaint with New York State’s Department of Financial Services.
For Essential Plan, Child Health Plus, and Medicaid Managed Care Plans, you can file a complaint with New York State’s Department of Health.
For help filing your complaint call the CHAMP helpline.
What about emergency or other types of appointments?
Emergency care must always be available right away and does not need to be with an in-network provider. Inpatient, residential treatment, and other urgently needed outpatient treatment may be available sooner than the wait times outlined in this handout depending on your type of health insurance.