Aetna has found itself in the odd position of being fined for covering something some members wanted, while not being fully up to speed covering another condition.
In Missouri, Aetna has agreed to pay $4.5 million to resolve a range of infractions in past practices, including errors in how members were notified of options for autism coverage, denial of autism therapy claims, and payments for abortions that needed policy riders under a 30-year-old state law.
The $4.5 million penalty is a record for Missouri insurance fines, and an example of how insurers have to adapt to varying state laws and, sometimes, the manifestations of the culture wars.
"This agreement demonstrates that we will hold Aetna or any other insurance company responsible to the people of this state, particularly children with autism disorders, to provide the coverage the law requires," said Missouri Governor Jay Nixon, who helped spearhead a 2010 law that guarantees coverage for applied behavioral analysis for autism.
Going back to 2013, Aetna's plans notified customers that autism benefits were optional, but did not require them to accept or waive the coverage, which led to at least some parents being denied ABA and autism therapy coverage for their children. Under the settlement, Aetna is agreeing to find customers who had been denied treatments and pay their claims with 9 percent interest.
In 2012 the insurer was also fined $1.5 million in Missouri for shortcomings in autism coverage, as well non-compliance with a 1983 state law requiring women to buy optional insurance to have their health plan cover an elective abortion.
Since then, over a 2.5 year period, Aetna found through an internal review, 9 claims for elective abortion were paid for health plans that did not have a rider. The insurer reported the findings to the Missouri Department of Insurance.
Under the terms of the settlement, Aetna will implement a compliance plan for both autism and abortion coverage, and have abortion claims more stringently reviewed, a spokesperson said. The insurer will have a three-year monitoring period, and $1.5 million of the $4.5 million will be waived if it fully complies the order after three years.
Missouri is among 10 states that limit health insurance coverage for elective abortions and one of 9 states requiring women to purchase a rider to have the procedure covered. The "Show-Me-State" also prohibits abortion coverage in ACA exchange plans and bars doctors' use of telemedicine to prescribe medication abortion.