On hold, waiting for a provider who may not be there.
By Mara Quinn | November 11, 2026
The directory said they were accepting new patients.
Four times out of five, they were not.
That finding sits at the center of two settlements New York Attorney General Letitia James announced on November 10, 2026, against Carelon Behavioral Health. Carelon administers behavioral health benefits for EmblemHealth, Anthem Blue Cross Blue Shield, Independent Health, and the Empire Plan. Those four plans together cover more than four million New Yorkers.
James's office found that 82 percent of behavioral health providers Carelon listed as accepting new patients for EmblemHealth members were effectively unavailable. The figure comes from a secret-shopper survey run by the Office of the Attorney General. Investigators posed as prospective patients. They called providers listed in the directory, one by one. Most could not be reached. Others were not accepting new patients, despite what the listing said. Others offered services that did not match what was advertised.
The settlements require Carelon to pay $2.35 million in penalties, fees, and costs to New York. They also require the company to make up to $8 million available to reimburse members. Eligible members can seek reimbursement for out-of-pocket costs for behavioral health care dating back to January 1, 2020.
When the Directory Lies
For most medical care, an inaccurate directory is an inconvenience. For behavioral health care, it can be something heavier.
People searching for a therapist or a substance use counselor often do so at a point of real need. The act of making that first call takes effort. When a listed provider cannot see you, you call the next name. Then the next. Each failed call adds weight to a search that was already difficult. Some people stop searching. The care does not happen.
This is what a ghost network produces. The term refers to providers listed in an insurance directory who are not actually available to members. Directories fall out of date in several ways. Providers leave practices. They change their insurance affiliations. Their patient slots fill. The legal obligation is straightforward: insurers and their administrators must keep directories current and accurate. When they do not, members rely on wrong information to make real decisions.
New York law is specific on this point. Insurers and their benefit administrators must maintain provider directories that reflect the actual state of the network. When those directories are inaccurate, members are misled. Some pay out of pocket for care that should have been covered, believing no in-network option exists. Others give up on finding care entirely.
A finding that 82 percent of listed providers are effectively unavailable means the directory is not a resource. It is a fiction most members have no way to detect until they are already turned away.
The Investigation
The Attorney General's investigation focused on Carelon's performance as the behavioral health administrator for EmblemHealth. Carelon is the company responsible for maintaining the provider network that EmblemHealth members use to access mental health and substance use treatment.
Investigators from the OAG used a secret-shopper approach. They tested a sample of providers listed in Carelon's directory as accepting new patients. For each one, investigators called and tried to schedule an appointment. They tracked whether the provider could be reached at all, whether they were accepting new patients despite the listing, and whether the services listed matched what was actually offered.
The result: 82 percent of those providers were effectively unavailable.
That is not an anomaly that falls within normal administrative lag. It describes a directory broadly disconnected from the actual state of the network it claimed to represent.
The settlements resolve the OAG's findings. They cover violations related to directory accuracy and Carelon's obligations to the members it serves across all four plans it administers in New York. The combined covered population is more than four million people.
The Settlement Terms
The financial terms split into two parts: what Carelon pays to the state, and what becomes available to members.
Carelon pays $2.35 million in penalties, fees, and costs. That money goes to New York State. Separately, Carelon must make up to $8 million available to reimburse members who paid for behavioral health care out of pocket.
Eligible members are those who could not find accurate in-network providers and paid more than they should have. They can file claims for covered services going back to January 1, 2020. That lookback, to the start of 2020, acknowledges that the problem did not start the day investigators found it.
The OAG has not specified a single claims process in the publicly released terms. Members who believe they paid out of pocket because of inaccurate directory listings should monitor communications from Carelon and the OAG for instructions on how to submit a reimbursement claim.
What Carelon Must Now Do
The settlements also impose forward-looking requirements. These are specific and measurable.
Directory accuracy comes first. If Carelon identifies an error in a provider listing, or is notified of one, it must correct the listing within two business days. It must verify every provider listing in the directory at least once every 90 days. Those verification obligations apply across all four plans Carelon administers in New York.
Appointment access gets concrete timelines. Urgent behavioral health care appointments must be available within 24 hours. First outpatient appointments must be available within 10 business days.
The 24-hour and 10-business-day standards set a floor. They give members, advocates, and regulators something specific to measure against. If Carelon cannot deliver appointments within those windows, the settlement gives the OAG grounds to act.
Taken together, the requirements push Carelon to do two things it was not demonstrably doing: keep its directories accurate, and ensure the access those directories promise actually exists.
A Pattern Bigger Than One Company
The Carelon settlements do not stand alone. They follow an earlier action James's office brought against EmblemHealth directly. That settlement required EmblemHealth to pay $2.5 million. The OAG's findings in that case showed that more than 80 percent of EmblemHealth's listed behavioral health providers were effectively unavailable. EmblemHealth covers approximately 1.5 million New Yorkers.
The parallel between the two sets of findings is worth examining. The EmblemHealth investigation and the Carelon investigation both used secret-shopper methods. Both found, independently, that roughly four out of five listed providers were not actually available. One investigation looked at the insurer. The other looked at the company the insurer hired to administer its behavioral health benefits. Both reached the same conclusion about the same scale of failure.
That consistency is hard to explain as coincidence. It points to a structural problem in how behavioral health provider networks were maintained and verified, not a temporary glitch or a single bad data feed.
The two enforcement actions together cover EmblemHealth's approximately 1.5 million members, plus the broader population across all four plans Carelon administers. The total reach exceeds four million New Yorkers. The combined financial terms add up to approximately $4.85 million in penalties and fees paid to the state, plus up to $8 million made available for member reimbursements under the Carelon settlement.
New York has pursued ghost network enforcement more aggressively than most states in recent years. These two settlements, reached in sequence and targeting different layers of the same problem, reflect a sustained approach. The earlier action held the insurer accountable. This one holds the company behind the insurer accountable.
What This Means for Mental Health Access
Enforcement actions do two distinct things. They address harm already done, and they set new expectations going forward.
The reimbursement fund addresses the past. Members who paid out of pocket because accurate in-network providers were not available can now make a claim. The lookback, to January 1, 2020, is a meaningful window. It tells members that years of inflated costs, not just recent ones, are eligible for recovery.
The forward requirements address what happens to the next person who opens the directory. If Carelon verifies every listing every 90 days and corrects errors within two business days, the directory should become materially more accurate than what investigators found. If urgent appointments must be available in 24 hours and first outpatient appointments within 10 business days, members have a clearer set of expectations about what their coverage actually delivers.
Whether those expectations hold depends on monitoring. Settlement terms are only as durable as the enforcement behind them. James's office will need to track compliance.
The attorney general stated her intent plainly after the settlements were announced. "These settlements will help people get the care they need and put money back in New Yorkers' pockets," James said. "My office will keep fighting until every New Yorker can get the mental health and substance use treatment they deserve."
The standard James named is not complicated. If a directory lists a provider as accepting new patients, that listing should be accurate. For more than four million New Yorkers covered by the plans Carelon administers, the evidence shows it was not accurate four times out of five.
The settlements say that has to change.
