PA Insurance Department Issues Fine Following Review Of How Insurance Covers Autism, Substance Use Disorder

Pennsylvania has levied a fine of $190,000 for violations relating to how insurance covered autism spectrum disorder and substance use disorder.

Pennsylvania Insurance Commissioner Jessica Altman said her office conducted a review of the practices and procedures of Aetna Inc., including Aetna Health Insurance Company, Aetna Health Inc., PA Corp., Health America, Inc., Health Assurance PA, Inc., and Aetna Life Insurance Company.

The fine was levied for claims wrongly denied and interest on delayed payments. In addition, officials have recovered more than $20,000 in  restitution for consumers.

Insurance officials noted other areas where violations were found:

• Improper claims denials, including incorrect policy language.
• Inaccurate calculation of consumers’ total out-of-pocket costs.
• Prompt payment and proper handling of claims.  The law requires all uncontested claims and uncontested portions of contested claims be paid within 45 days of receipt.
• Prompt notification of cancellations and eligibility determinations.

“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,” Pennsylvania Insurance Commissioner Jessica Altman said in a statement. “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.”

The review has found that Aetna has addressed many of the violations through company practices and procedures. State officials said they will be verifying that correction actions have taken place.

The Pennsylvania Insurance Department plans to conduct similar examinations on all of Pennsylvania’s major health insurers.

According to officials the state’s Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires health insurance plans allow for the same of coverage for mental health and substance use disorder care as for medical or surgical care.

Altman also urged consumers to contact the department’s Bureau of Consumer Services if they think their plan does not meet parity requirements for mental health and substance use disorder coverage or have questions about the benefits to which they are entitled.