EmblemHealth reaches settlement with NY over denial of mental health claims
The state attorney general Tuesday announced a settlement with the insurer EmblemHealth for denying mental health treatment to many of its members.
The settlement, which includes a $1.2 million civil penalty and could result in more than $31 million in reimbursements to members, is part of an ongoing investigation by Attorney General Eric Schneiderman and is the third settlement on mental health claims with a health insurer this year.
The attorney general's health care bureau found that since 2011, EmblemHealth of Manhattan, which has 3.4 million members statewide in its HIP and GHI divisions, had issued 64 percent more denials for behavioral health coverage than for medical cases.
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Since 2006, New York has required that insurers provide mental health coverage equal to that provided for other health conditions. Federal law enacted in 2008 prohibits health plans from charging more for or limiting treatment of mental health or substance use conditions compared with medical infirmities.
"Insurers must comply with the laws -- and they must treat people with mental health and substance abuse conditions as they do those with medical conditions," Schneiderman said in a statement.
Charlene Maher, EmblemHealth's chief marketing officer, said the company "understands the importance of providing access to quality behavioral services."
"Policies and procedures dealing with the issues raised by the attorney general have been put in place, as well as enhanced compliance oversight," she said in a statement.
Under the agreement, EmblemHealth has agreed to provide an independent review of claims to those members denied mental health coverage from 2011 to the present. The attorney general estimated this could result in more than $31 million in reimbursements to more than 15,000 members.
The company also will be monitored by "an external entity," file an annual compliance report and pay $1.2 million to the attorney general.
The attorney general reached a settlement in January with Connecticut-based Cigna Corp. for denying claims for nutritional counseling for mental health conditions, particularly eating disorders, and with MVP Health Care of Schenectady in March for denying 40 percent more mental health and substance abuse claims than medical claims.
Heather, a Northport mother of a 15-year-old daughter diagnosed last year with anorexia nervosa, said EmblemHealth covered her daughter's many hospitalizations for dangerously low blood pressure -- a consequence of the disease -- as well as an outpatient treatment program. But the mother, who asked that her last name not be used to protect her daughter, said the company denied coverage for a residential treatment program although the teenager continued to lose weight and showed signs of heart damage.
"The problem was they would treat the medical defect but they were never dealing with the mental disorder, and the outpatient program wasn't working," she said.
The mother said only after the intervention of the attorney general, her employer and her own lobbying did the insurance company agree to pay for a residential program. That helped, she said, and her daughter is now "doing phenomenally well."