Tag: Health Insurance

Aetna Fined Over Autism And Substance Abuse Coverage

State regulators in Pennsylvania fined health insurer Aetna  this week, for violating rules on coverage of drug and alcohol abuse treatment and coverage of autism spectrum disorder.

A federal law called the Mental Health Parity and Addiction Equity Act generally forbids health carriers from discriminating against coverage for mental health conditions or substance abuse disorders.  These laws are important because health insurers are often incentivized to deny coverage for mental health and substance abuse conditions, as they often require costly inpatient therapy.  Fighting such denials is hard because unlike conditions like a broken bone or the flu, mental health and addiction disorders can be harder to objectively document. Many states have similar rules.

Pennsylvania regulators found Aetna violated these rules.  The state identified “confusing policy language which could have led consumers to inaccurately believe they did not have coverage for certain substance use disorder services.”

Aetna also imposed improper copays, coinsurance, and visit limits, as well as illegally requiring prior authorization for treatment.

Happy New Year – Washington Health Insurers Are Now Required to Expand Contraceptive Coverage

In 2019, Washington health insurers are required to expand contraceptive coverage. Any health plan in Washington issued or renewed on or after Jan. 1 must now provide coverage for the following:

  • All FDA-approved contraceptives, including drugs and devices; and
  • Voluntary sterilization procedures.

The new law also requires coverage for consultations, examinations and procedures necessary to obtain contraceptives or voluntary sterilization.  Importantly, most health insurers are now prohibited from imposing copayments, deductables, or other cost sharing on contraceptive coverage.

The law also broadly prohibits insurers from limiting insureds’ access to contraceptives.  For instance, insurers may no longer deny contraceptive coverage because the insured changed contraceptives recently.

Washington’s legislature enacted the expanded coverage requirements in order to guarantee equal access to reproductive health benefits and services.  The new law notes:

Neither a woman’s income level nor her type of insurance should prevent her from having access to a full range of reproductive health care, including contraception and abortion services;…Restrictions and barriers to health coverage for reproductive health care have a disproportionate impact on low-income women, women of color, immigrant women, and young women, and these women are often already disadvantaged in their access to the resources, information, and services necessary to prevent an unintended pregnancy or to carry a healthy pregnancy to term;…Existing state and federal law should be enhanced to ensure greater contraceptive coverage and timely access for all individuals covered by health plans in Washington to all methods of contraception approved by the federal food and drug administration;…

Texas Judge Strikes Down Affordable Care Act

A federal judge in Texas has ruled the Affordable Care Act (a/k/a “Obamacare”) can no longer be enforced.  The judge determined the Act cannot function without its individual mandate requiring virtually all Americans to carry minimum health coverage.  Congress repealed the ACA’s individual mandate at the end of 2017.

If the ruling becomes the law of the land, it will have serious implications for health insurance coverage.  Among other things, the ruling eliminates the ACA’s minimum coverage requirements including guaranteed coverage for people with pre-existing health conditions, emergency medical treatment, maternity and newborn care, mental health and substance abuse treatment, prescription drugs and pediatric care.

The ruling has the potential to eliminate health coverage for about 17 million Americans  — including millions who gained coverage through the ACA’s expansion of Medicaid.   Policyholders with pre-existing conditions could see significant premium increases once the ACA’s prohibition against increased charges for pre-existing conditions become void.

For the time being, the ruling has little practical impact for insureds.  The federal Centers for Medicare and Medicaid Services emphasized “There will be no impact to enrollees’ current coverage or their coverage in a 2019 plan.”  For now, the biggest concern is that the ruling will confuse insureds into failing to purchase coverage during open enrollment,  which CMS states will proceed normally.

Know Your Rights Under Washington’s Patient Bill of Rights

Health insurance policyholders are guaranteed specific rights under Washington State’s Patient Bill of Rights.  The law’s purpose is to guarantee health insurance policyholders have access to quality health care.  If you find yourself in a dispute with your health insurance carrier, knowing these rights may help.

Policyholders Have The Right To Know About Their Coverage.  Health insurers must provide prospective policyholders specific information before the policyholder purchases coverage.  This include:

  • A list of doctors, hospitals and other providers who participate in the insurance plan.
  • An explanation of the policyholder’s premiums and charges;
  • How the policyholder can fight a wrongful claim denial, including through filing grievances;
  • Coverage information, including information about what prescription drugs are covered;
  • Explanations of any exclusions or limitations that apply to your coverage;
  • Information about the insurer’s efforts to protect policyholders’ confidential information;
  • Any applicable copayment, delectable, and/or coinsurance charges.

Policyholders Have The Right To Access Medical Treatment. Health insurers must allow policyholders to choose their own Primary Care Provider, although the insurer is permitted to require the policyholder to choose from a specific list.  The insurer must also allow policyholders to change providers if necessary.  Insurers must also  maintain adequate networks containing every category of licensed medical providers.  If needed to treat the policyholder’s condition, the insurer must provide referrals to specialists.  Finally, health coverage must include women’s health care.

Policyholders Have The Right To Challenge Claim Denials.  Health insurers must respond to complaints about wrongful coverage denials through a formal grievance process that is prompt, fair and impartial.

Health Insurer Ordered to Pay $25.5 Million For Wrongful Cancer Treatment Denial

In a timely followup to last week’s discussion of how to fight health insurance denials, this week an Oklahoma jury ordered health insurer Aetna to pay $25.5 million for denying coverage for insured’s Orrana Cunningham’s cancer treatment bills.   Aetna had denied coverage for Orrana’s treatment in 2014 on the basis it was “experimental;” after being denied coverage for this treatment, Orranna passed away the next year.

The case illustrates one of the classic issues in a health insurance or disability insurance coverage dispute.  In typical cases, the insured’s family doctor or specialist prescribes treatment or time off work after examining the insured, diagnosing an illness or injury, and identifying appropriate treatment.  The insurer typically denies coverage based on the opinions of a physician on the insurer’s payroll; these “file review” physicians usually don’t practice medicine in the conventional sense, but work for the insurer reviewing medical records of insureds to advise the company whether to cover the treatment or disability.

As you could imagine, the doctor on the company’s payroll has a powerful incentive to tell the insurer what it wants to hear, which is typically that there is no coverage and the insurer need not pay for costly treatment.   Moreover, the insurer’s physician has no history of treating the patient, virtually never examines the patient, and limits their analysis to a cursory review of the patient’s medical records.  In many cases, the physician is so overworked they give little or no attention to the patient’s medical history or treatment needs before denying coverage.

That’s what happened to Orrana Cunningham.  In the course of the lawsuit, it came out that Aetna’s doctor reviewing Orrana’s medical records was pressured to review more than 80 patients’ cases a day.  The plaintiffs also told the jury Aetna’s file reviewers were unqualified, and were compensated based on Aetna’s profit – not based on getting claims right.

The plaintiffs’ attorney reported a juror approached him after the trial and emphasized the jury “wanted to send a message to Aetna” to fix a broken health insurance system.