By Jessica Grillo, J.D., Legal Advisor for the Kennedy Forum

On November 5, 2018, the Pennsylvania Insurance Department issued a Market Conduct report on Aetna’s subsidiaries, Aetna Health Insurance Company, Aetna Health Inc., PA Corp., Health America, Inc., Health Assurance PA, Inc., and Aetna Life Insurance Company. The Market Conduct exam covered the timeframe of January 1, 2015 – March 31, 2016 and focused on policies and procedures in the following areas: Operations and Management, Complaints, Producer Licensing, Policyholder Services, Underwriting and Rate, Claims, Grievances, Network Adequacy, Provider Credentialing, Quality Assessment and Improvement, and Utilization Review.

The report uncovered a variety of deficiencies, some of which included mental health and substance use disorder benefits issues. More specifically, the report found that:

• For Autism Spectrum Disorder (ASD) Claims, policy documents excluded coverage for ASD unless the child is diagnosed with ASD within onset prior to age three, coverage limits were applied for diagnostic assessment of ASD and for treatment of ASD and quantitative treatment limitations (QTLs) and non-quantitative (NQTLs) were imposed with respect to mental health benefits not in parity with medical/surgical benefits.
• For Substance Use Disorder and Chemical Recovery Claims, Aetna failed to provide inpatient detoxification, non-hospital residential and outpatient services for alcohol or other substance use and dependency and imposed a NQTL with respect to mental health benefits not in parity with medical/surgical benefits.
• For Mental Health Claims, Aetna imposed a QTL with respect to mental health benefits not in parity with medical/surgical benefits.
• For Inpatient and Outpatient High Dosage Opioid Addiction Treatment Claims, Aetna failed to provide inpatient detoxification, non-hospital residential and outpatient services for alcohol or other substance use and dependency and imposed a NQTL with respect to mental health benefits not in parity with medical/surgical benefits.

Upon completion of its review, the Pennsylvania Insurance Department made several recommendations. First: Aetna must review and revise internal control procedures to ensure compliance with the mental health and substance use disorder parity requirements relating to NQTLs and QTLs. Second: Aetna must ensure that diagnostic assessment of ASD and treatment of ASD are covered for covered individuals under 21 years of age. Third: Aetna must provide documentation to the Pennsylvania Insurance Department within 30 days demonstrating that all claims found in violation during the examination were processed and paid including due interest and restitution.

The signed Consent Order further required Aetna to cease and desist from engaging in prohibited activities described in the Report, file an affidavit stating under oath that it will provide each of its directors a copy of the Report and related Orders, comply with all recommendations in the Report and to pay $190,000 to the Commonwealth of PA in settlement of the violations.

To read the full report, click here.

The Massachusetts Office of the Attorney General (OAG) also conducted an investigation into certain acts and practices of Aetna concerning its’ members’ access to Behavioral Health care services. In lieu of litigation, on December 11, 2018, the OAG and Aetna agreed to enter an Assurance of Discontinuance wherein Aetna agreed to maintain a Behavioral Health Provider network and directory that is adequate in number and types of providers to ensure all covered behavioral health services are accessible to Aetna members without unreasonable delay. Aetna also agreed to pay $75,000 to the AGO for civil penalties and attorneys’ fees. To learn more, click here.

Key Takeaway

Results such as these help to improve internal procedures and clarify policy language so that consumers are well informed of their rights and insurance coverage benefits. Policy examinations also help state Insurance Departments maintain oversight to safeguard against improper roadblocks for mental health and substance use disorder benefits. Consumers should contact their state Insurance Department to report concerns about mental health parity or if they have questions about their benefits.

The Kennedy Forum Legal Taskforce seeks to create positive case law in ERISA, Federal and State Parity and Disability cases, nationwide. The group is comprised of expert litigators in the field who share a common passion for pursuing equality and justice for those who have been wrongfully denied mental health and addiction treatment services.

Parity Resources from The Kennedy Forum

The Kennedy Forum’s “Don’t Deny Me” campaign empowers patients and their loved ones to report illegal insurance denials of mental health and addiction treatment, and fight for their parity rights. The campaign is sparking a consumer-driven movement that pressures elected officials, insurance commissioners, and attorneys general to enforce The Federal Parity Law. This law requires most insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than illnesses of the body, such as diabetes or cancer. Learn more at www.DontDenyMe.org and join the conversation using#DontDenyMe.

Parity Track is a website where policymakers, journalists, consumers, and others can track legislative, regulatory, and legal parity activities in all 50 states and at the federal level to monitor implementation and best practices.