Emblem will establish a restitution process to repay members who paid out-of-pocket for mental health services because they were unable to find an in-network provider.
EmblemHealth will pay $2.5 million after an investigation by the Office of the Attorney General in the State of New York found the insurer repeatedly failed to ensure New Yorkers could access mental healthcare services.
Emblem maintained inaccurate provider directories, overstated the availability of in-network mental health and substance use disorder providers, and failed to comply with state and federal behavioral health parity laws, leaving many New Yorkers unable to find affordable care, according to New York State Attorney General Letitia James.
Under the settlement, Emblem will pay $2.5 million in penalties and fees, provide restitution to members who were forced to pay out-of-pocket for mental healthcare, and implement reforms to improve access to mental health and substance use disorder treatment, the AG’s office said.
WHY THIS MATTERS
The investigation found widespread ghost networks – a health insurance provider directory that incorrectly lists doctors, specialists or facilities as “in-network.” The OAG determined that more than 80% of surveyed behavioral health providers Emblem listed as accepting new patients were effectively unavailable. Emblem’s own surveys showed similar results, the AG’s office said.
The OAG launched an investigation into Emblem in 2023. The investigation found that Emblem’s directories contained many errors, including listings for providers who were unreachable, no longer practicing, not accepting new patients, or not actually in the plan’s network, according to the AG’s office.
Attorney General Letitia James said, “Health insurers cannot mislead consumers with inaccurate provider directories while families are left without care. We are requiring Emblem to make meaningful changes so that New Yorkers can actually access the behavioral health treatment their insurance promises.”
If Emblem provides inaccurate provider directory information that leads a member to receive an unexpected out-of-network bill, the company must ensure the member pays only their usual copay or deductible.
In addition, Emblem is required to take steps to ensure members can access mental health and substance use disorder treatment appointments within 24 hours for urgent care and 10 business days for an initial outpatient appointment. If a member is unable to secure a timely appointment with an in-network provider, Emblem must allow the member to see an out-of-network provider but only pay their in-network copay or deductible.
The settlement also requires Emblem to carry out a behavioral health provider recruitment and retention plan to expand its network statewide.
THE LARGER TREND
Emblem covers approximately 1.5 million New Yorkers through commercial plans, Medicaid managed care, Child Health Plus, the Essential Plan and New York City employee health plans.
A group of government employees from New York state sued EmblemHealth in December 2025, alleging that it violated state law by failing to provide accurate information about its healthcare plan, according to NBC News.
The plaintiffs included six New York City government workers who allege that EmblemHealth’s ghost network had significantly impeded their access to mental healthcare. The American Psychiatric Association, another plaintiff in the suit, alleged that EmblemHealth misrepresented the coverage that psychiatrists offer, which the lawsuit says is false advertising, according to the report.
The lawsuit is one of at least seven filed in the last two years in connection to inaccurate provider listings from insurance companies, according to the NBC report.
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