Aetna Sued in Pa. for Parity Lapses in Autism, Substance Use Disorder Coverage
Abstract
The Pa. Department of Insurance says it has recovered more than $20,000 in restitution for consumers from wrongly denied claims and interest on delayed payments and is working with the company on additional restitution.
The Pennsylvania Department of Insurance has fined Aetna Inc. $190,000 for policies that the department says violate the federal mental health parity law, especially regarding coverage of autism and substance use disorders.
Insurance Commissioner Jessica Altman last month announced the results of a market conduct examination looking at the practices and procedures of Aetna Inc. and its subsidiary companies operating in Pennsylvania. The report covers the period from January 2015 through March 2016.
“While the department reviewed many priority areas through this examination, a significant focus was on the company’s compliance with laws requiring parity of coverage for substance use disorders and mental health, which must be offered at the same level of benefits as medical or surgical treatment,” Altman said in a statement on the Department of Insurance website. “In this area, I am disappointed that we did find violations relating to autism coverage, as well as confusing policy language which could have led consumers to inaccurately believe they did not have coverage for certain substance use disorder services. Violations included incorrect application of copays, coinsurance, and visit limits, as well as violations involving prior authorization for treatment and step therapy.”
Altman said in the statement that adequate coverage of mental illness and substance use disorders was an integral part of Gov. Tom Wolf’s battle against the opioid crisis.
The Department of Insurance noted other areas in which violations were found. Among them:
Improper claims denials, including incorrect policy language.
Inaccurate calculation of consumers’ total out-of-pocket costs.
Failure to provide prompt payment and proper handling of claims. The law requires all uncontested claims and uncontested portions of contested claims to be paid within 45 days of receipt.
Failure to provide prompt notification of cancellations and eligibility determinations.
To date, the Insurance Department has recovered over $20,000 in restitution for consumers from claims wrongly denied and interest on delayed payments and is working with the company on additional restitution, according to the department’s website.
The report released last month states that Aetna has addressed many of the noted violations through changes in company practices and procedures, and the department will be verifying that these corrective actions have taken place through a reexamination process.
The insurance department is conducting similar market conduct examinations, emphasizing mental and substance use disorder parity, of all of Pennsylvania’s major health insurers to ensure they are in compliance with state and federal laws.
This is the second market conduct examination for which the department has issued a report. The first report was issued to Blue Cross of Northeast Pennsylvania in early 2018.
“Mental health and substance use disorder parity in individual and small and large group plans is a critical protection for consumers,” said Altman. “Gov. Wolf has made it a priority that the Department of Insurance be vigilant in ensuring that Pennsylvanians are receiving the benefits that they are entitled to under state and federal law.” ■
The report on Aetna can be accessed here.
