Two New York settlements with Carelon Behavioral Health establish new requirements for provider directories, appointment access and reviews of substance-use-disorder treatment. The Attorney General's Office announced the agreements November 10 after separate investigations into inaccurate mental-health listings and coverage decisions. Carelon administers behavioral-health benefits for more than four million New Yorkers through plans including EmblemHealth, Anthem Blue Cross Blue Shield, Independent Health and the Empire Plan.
The financial terms include $2.35 million in penalties, fees and costs and as much as $8 million in restitution for eligible members who paid for out-of-network mental-health care. Other eligible members may receive repayment for out-of-pocket bills associated with Carelon denials. The precise amount returned will depend on eligibility and valid claims, so members should not assume that the announced ceiling is a guaranteed distribution.
The directory investigation used a secret-shopper review. The Attorney General reported that 82 percent of surveyed Emblem behavioral-health providers listed as accepting new patients were effectively unavailable. Entries included clinicians who could not be reached, no longer practiced, did not accept new patients or were not actually in the network. A directory can look broad on paper while offering few usable appointments, which is why availability testing matters alongside provider counts.
Under the settlement, Carelon must correct reported listing errors within two business days and verify provider information every 90 days. It must confirm that a provider is accepting new patients before making a referral, create ways for members and clinicians to flag inaccuracies, and remove providers who have submitted no claim in 90 days unless they confirm continued participation. Quarterly secret-shopper surveys and published results add an external test to routine database maintenance.
The agreement also sets access standards. Urgent appointments must be available within 24 hours, and an initial outpatient appointment must be available within ten business days. When a member says no in-network appointment can be secured, Carelon has three business days to locate an appropriate provider. If it cannot, the member must be permitted to use an out-of-network provider while paying the normal in-network cost. The same protection applies when a member was wrongly told that a provider was in network.
A second investigation concerned the criteria used to review substance-use-disorder treatment. New York has required insurers since 2017 to use medical-necessity standards approved by the state Office of Addiction Services and Supports. The Attorney General found that Carelon did not consistently use those standards. The official record notes that independent reviewers overturned substantial shares of appealed denials involving several plans between 2019 and 2022.
An independent monitor will examine provider information, appointment availability, out-of-network use, reimbursement and network size, with reports to the Attorney General every six months. Carelon must also develop a recruitment and retention plan, reduce administrative burdens and invest in scarce specialties, including child and adolescent psychiatry and psychiatric nurse practitioners. Those structural requirements are intended to make the network more usable rather than merely improve the website.
Members seeking care should keep a dated record of providers called, the response received, requests made to Carelon and any authorization or denial number. That documentation can establish when the three-business-day clock should apply and support a request for in-network cost sharing on out-of-network care. A person in immediate danger should use emergency services rather than wait for an administrative response.
The agreements convert directory accuracy into a measurable access obligation. Their practical value will depend on whether patients can obtain appointments within the stated time, whether complaints produce prompt corrections and whether eligible people receive restitution. Published survey results and the monitor's findings will be important for distinguishing formal compliance from a network that works when a New Yorker actually seeks treatment.
Primary sources: New York Attorney General Carelon settlement announcement. Reviewed November 11, 2026. Development: Settlements announced November 10, 2026.