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Aetna Market Conduct Report Notes Autism and Substance Use Disorder Coverage Violations, General Compliance Overall


Harrisburg, PA - Insurance Commissioner Jessica Altman today announced results of a market conduct examination conducted on 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 report, which covers the period from January 2015 through March 2016, found substantial areas of compliance with insurance laws; however, Altman noted concerns with the companies’ coverage for services relating to autism spectrum disorder and substance use disorder. The examination also covered company operations and handling of consumer complaints, where no violations were found.  

 “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 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.”

“Making sure Pennsylvanians receive the substance use disorder benefits to which they are entitled under their health insurance coverage is a key part of Gov. Wolf’s battle against the opioid crisis. These market conduct examinations are an important way to make sure this is happening,” Altman added.

The Insurance Department noted other areas where violations were found, including:

·         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.

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. The department has also levied a penalty of $190,000 for violations found during the examination.

As noted in the report, Aetna has addressed many of the noted violations through changes in company practices and procedures, and the Insurance Department will be verifying that these corrective actions have taken place through a reexamination process.  The Insurance Department also acknowledges the company has been cooperative in its response to the violations.

“The most important result of this report for consumers is that Aetna will continue to improve its procedures, including providing correct language in policies, so consumers can make informed decisions with regard to the policy they are buying based on the policy’s coverage,” Altman said. “The results of this examination will also help the Insurance Department in our future oversight of the company.”

The Insurance Department is in the process of conducting similar market conduct examinations, emphasizing mental health and substance use disorder parity, on all of Pennsylvania’s major health insurers to ensure they are in compliance with state and federal law. This is the second of these exams for which the Department has issued a report.  The first exam report was issued to Blue Cross of Northeast Pennsylvania in early 2018.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires health insurance plans to contain the same level of coverage for mental health and substance use disorder care as for medical or surgical care. This coverage includes quantitative limitations (copays, deductibles, and limits on inpatient or outpatient visits that are covered) and non-quantitative limitations (pre-authorizations, providers available through a plan’s network, and what a plan deems “medically necessary”). The federal law was incorporated into Pennsylvania law in 2010 through Act 14.

Currently, parity is required for individuals with the following health plans:

  • Individual and small group health plans, as required by the Affordable Care Act;
  • Large group health insurance plans which offer substance use disorder and mental health coverage.  Fully insured plans are required to offer this coverage under Pennsylvania Act 106.
  • Children’s Health Insurance Program (CHIP) and Medicaid Managed Care.

The Insurance Department currently reviews all individual, small group and large group policies to ensure those policies contain all state and federal policy requirements, including mental health and substance use disorder parity. However, the Insurance Department has found even in policies containing language meeting all requirements, lack of appropriate administrative oversight or other operational problems have led to mishandling of these important consumer protections.

“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 Insurance Department be vigilant in ensuring that Pennsylvanians are receiving the benefits that they are entitled to under state and federal law.”

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.

Information on substance use disorder and mental health coverage requirements is available on the Health page at

MEDIA CONTACT: Ron Ruman 717-787-3289 

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