Nation’s Largest Health Insurer Fined Over Autism Claims
PHILADELPHIA — Pennsylvania officials this week announced a $1 million fine against insurance giant UnitedHealthcare for denial of, or sometimes failure to pay, customers’ claims relating to mental health care.
UnitedHealthcare also inaccurately calculated consumers’ total out-of-pocket costs for claims relating to autism, according to the state Insurance Department. The company’s actions were in violation of the federal Mental Health Parity and Addiction Equity Act of 2008, officials said.
The Mental Health Parity act requires health insurance plans to contain equivalent levels of coverage for mental health and substance use disorder care as for medical or surgical care, the Insurance Department said. This law covers quantitative limitations, such as copays, deductibles and limits on inpatient or outpatient visits that are covered, plus other restraints on getting care, such as pre-authorizations, the number of providers available through a plan’s network, and what a plan deems “medically necessary.”
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UnitedHealthcare said it worked closely with state officials to address their concerns.
“While we have already made changes, we will continue to make improvements to help individuals get care under their plans,” the company said in a statement. “We will collaborate with the Insurance Department to help more Pennsylvanians meet their mental health needs by providing additional resources and education to help them understand and access their benefits.”
In addition to paying the fine, UnitedHealthcare agreed to spend $800,000 on a public outreach campaign to educate Pennsylvania consumers about their mental health and substance use disorder benefits, and to pay an unspecified amount of restitution to consumers whose claims were wrongly denied, who overpaid out-of-pocket-expenses and who incurred interest on delayed claims.
The fine was the result of a “market conduct examination” that covered January 2015 through March 2016.
“Market conduct examinations provide the department with an opportunity to review a company’s practices and procedures, including its compliance with laws requiring parity of coverage for substance use disorders and mental health,” Insurance Commissioner Jessica Altman said in a news release. “The violations within this area were very disappointing, as they negatively affected some of our most vulnerable populations.”
In January, the Insurance Department fined Aetna $190,000 after a market conduct review found that the insurer had violated rules on coverage of drug and alcohol abuse treatment and coverage of autism spectrum disorder.
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