Illinois fines Celtic health insurer $1.25 million

The Illinois Department of Insurance fines health insurer Celtic Insurance Co. with $1.25 million for allegedly not covering mental health and addiction at the same levels as other medical issues.

Celtic sells health insurance plans called Ambetter on the Affordable Care Act exchange and is a subsidiary of health insurance giant Centene.

Centene did not immediately respond to a request for comment Tuesday.

The department alleged that Celtic violated the Mental Health Parity and Addiction Equity Act, which is a federal law that requires health insurance plans to have equivalent levels of coverage for mental health and substance use disorders as for medical or surgical cares. Illinois law extends this federal law.

Specifically, the department says Celtic requires prior authorization for all substance use disorder claims. Prior authorization is when a patient must receive approval from an insurance company to cover a treatment or drug before the patient can receive it. It’s a requirement that many criticize as creating barriers to care.

The company also allegedly required prior authorization to obtain drugs for ADHD, depression, drug overdose and treatment for opiate withdrawal symptoms, among others, according to the department.

The department says Celtic has limited the amounts of anti-anxiety drugs, antipsychotics, smoking cessation drugs, schizophrenia, addiction treatment and HIV/AIDS it will cover.

The department also said Celtic violated the Network Adequacy and Transparency Act, which requires insurers to maintain an adequate network of providers. A provider network is a group of doctors and other health care professionals who contract with an insurance company to provide care to its members. Celtic failed to provide its members with an up-to-date and accurate directory of its in-network health care providers, according to the department.

“We know how important it is to have health insurance coverage for mental health and substance use disorder treatment, especially since the pandemic has affected so many people,” Illinois Department of Insurance Director Dana Popish Severinghaus said in a news release. “In Illinois, parity is the law and companies cannot create barriers to treatment for patients in need. Our comprehensive examination of market conduct revealed that Celtic did just that, and we will continue to hold insurers accountable under the law to help improve fairness and access to health insurance coverage.”

The findings come from a market behavior study conducted by the Illinois Department of Insurance covering the period 2018 to 2020. Such reviews, conducted periodically, verify an insurer’s compliance with laws and regulations designed to protect consumers.

Celtic and Centene also face a federal lawsuit filed by consumers in Illinois and other states alleging the insurers defrauded them by overcharging them for plans that didn’t deliver the benefits they promised.

Consumers seeking class-action status for the lawsuit allege the companies maintained incorrect lists of provider networks, making it difficult for them to find treatment and care. The lawsuit also alleges that Ambetter’s plans “routinely refuse to pay for medical services and drugs that the plan purports to cover.”

Centene said in a statement in August that it and its subsidiaries are working “to help members and their families gain access to comprehensive, affordable and high-quality Marketplace health plans.”

“This lawsuit is just another attack on the health insurance marketplace and the ACA itself,” Centene said in the statement. “Centene will vigorously fight this lawsuit and continue to uphold the (Affordable Care Act’s) important goal of improving the health of our communities, one person at a time.”

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