Aetna, one of the nation's top five largest health insurers, is being sued in a class-action lawsuit filed in U.S. District Court in the Central District of California. The complaint alleges that Aetna illegally denied claims for mental health residential treatment services in violation of the The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). [FN1]
In 2019, the plaintiff, who had a large (employer) group Aetna plan, enrolled his 16-year-old son who has autism spectrum disorder (ASD) in a mental health residential treatment center located in Utah. Aetna denied the plaintiff's claim for reimbursement for his son's treatment at the residential facility based upon Aetna's internally developed (or proprietary) utilization management criteria. The plaintiff alleges that this internal criteria is far more restrictive than generally accepted professional standards in order to "minimize the number of claims accepted and thereby maximizing Aetna’s own profits." The attorney representing the plaintiff stated, "The standards they [Aetna] are using and the requirements for mental health facilities don’t exist for surgical benefits or physical health benefits."
MHPAEA is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical (M/S) benefits. In fact, MHPAEA requires that coverage for MH/SUD be no more restrictive than coverage for M/S services.
The pandemic has highlighted the importance of mental and behavioral health services. Mental wellness is just as important as physical wellness. Navigating the health insurance world of in-network, out-of-network, medical necessity, and prior authorization can be confusing and challenging.
If you are insured, do you understand your behavioral health benefits or have you had difficulty accessing behavioral health benefits? If you are a carrier offering MH/SUD benefits, do you understand MHPAEA requirements for purposes of compliance? If you answered no to either question, then please consider calling Pacific Apex Law Group for assistance at (888) 609-8718. We're here to help.