Note: The content in this article applies to enrollees of The Empire Plan.
MHSU Program
Carelon Behavioral Health is the plan administrator for Mental Health and Substance Use for The Empire Plan. They offer a number of services including:
- Clinical Referral Line: 24/7 access to specialized clinicians to find providers and arrange care, ensuring in-network benefits.
- Mental Health and Substance Use Coverage: Covers medically necessary inpatient and outpatient services for behavioral health, including addiction.
- Virtual Care (Telehealth): Access to online therapy through partners like Talkspace.
- ADHD: Screening tools, education, and assistance with assessing treatment options for children.
- Eating Disorders: Specialized education and screening programs.
- Intensive Case Management: For members with more severe symptoms.
- Neurofeedback: Coverage for mental health conditions such as anxiety, depression, and ADHD.
Network Providers
- Visit the Carelon Empire Plan website and navigate to Find Providers. From there, you can search by a number of categories including ages, specialties, languages, and more.
- You can also call the Clinical Referral Line at 1-877-7-NYSHIP. Select option-3 at each prompt to reach the clinical referral line under mental health/substance use program as enrollees. This service is confidential and available to you 24 hours a day, every day of the year.
Other Options
Carelon guarantees access to a network provider with the following wait times:
- Initial outpatient facility or clinic appointments: Within 10 business days
- Initial appointments with other behavioral health professionals: Within 10 business days
- Follow-up appointments after a hospital discharge or ER visit: Within 7 calendar days
- These standards may be met through telehealth services unless a member specifically requests an in-person appointment.
If you are unable to schedule an appointment with an in-network behavioral health provider within these timeframes, you or your authorized representative may submit an access complaint by phone, in writing or electronically. Once received, Carelon will:
- Attempt to identify an in-network provider who can meet the wait time requirements within 3 business days.
- If no in-network provider is available to meet the appointment wait time standards, the member may be approved to seek care from an out-of-network provider. This approval is contingent upon the out-of-network provider:
- Being able to meet the applicable appointment wait time standards
- Being reasonably located, if an in-person appointment is requested
- And not charging fees that are excessive or unreasonable
While The Empire Plan will not identify or arrange the out-of-network provider on the member’s behalf, services from an approved provider will be covered at the in-network cost-sharing level.
Complaints can be submitted by calling the phone number on your insurance card. You can also submit a complaint on the website, by fax (1-866-636-1788), or mail (Carelon Behavioral Health, Inc., Attention: Grievances and Appeals, PO Box 1864, Hicksville , NY 11802-1864).
