Attorney General James and U.S. Department of Labor Deliver $14 Million to Consumers Who Were Denied Mental Health Care Coverage

 

 UnitedHealthcare Unlawfully Denied Coverage to 20,000 New Yorkers for Mental Health and Substance Abuse Treatment

 New York Attorney General Letitia James and the U.S. Department of Labor (USDOL) today announced landmark agreements with UnitedHealthcare (United), the nation’s largest health insurer, to resolve allegations that United unlawfully denied health care coverage for mental health and substance use disorder treatment for thousands of Americans. As a result of these agreements, United will pay approximately $14.3 million in restitution to consumers affected by the policies, including $9 million to more than 20,000 New Yorkers with behavioral health conditions who received denials or reductions in reimbursement. New York and federal law requires health insurance plans to cover mental health and substance use disorder treatment the same way they cover physical health treatment. The agreements — which resolve investigations and litigation — address United’s policies that illegally limited coverage of outpatient psychotherapy, hindering access to these vital services for hundreds of thousands of New Yorkers for whom United administers behavioral health benefits. In addition to the payment to impacted consumers, United will lift the barriers it imposed and pay more than $2 million in penalties, with $1.3 million going to New York state.  

“In the shadow of the most devastating year for overdose deaths and in the face of growing mental health concerns due to the pandemic, access to this care is more critical than ever before,” said Attorney General James. “United’s denial of these vital services was both unlawful and dangerous — putting millions in harm’s way during the darkest of times. There must be no barrier for New Yorkers seeking health care of any kind, which is why I will always fight to protect and expand it. I thank Secretary Walsh for his partnership on this important matter.” 

“Protecting access to mental health and substance use disorder treatment is a priority for the Department of Labor and something I believe in strongly as a person in long-term recovery,” said U.S. Secretary of Labor Marty Walsh. “This settlement provides compensation for many people who were denied full benefits and equitable treatment. We appreciate Attorney General James and her office for their partnership in investigating, identifying, and remedying these violations.” 

New York’s behavioral health parity law — originally enacted as “Timothy’s Law” in 2006 — and the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) require insurance coverage for mental health and substance use disorder treatment to be no more restrictive than insurance coverage for physical health conditions. The agreements are the product of the first joint state-federal enforcement of these laws.  

The Office of the Attorney General's (OAG) complaint — which parallels USDOL’s complaint — was filed in the U.S. District Court for the Eastern District of New York, along with the agreements. Each complaint describes two practices by United that the agencies allege violated behavioral health parity laws through discriminatory practices that improperly restricted coverage of psychotherapy:

1) Reimbursement Penalty

United penalized thousands of New York members by making them pay more than they should have for psychotherapy with non-physicians, who are the predominant providers of this service. United did so by reducing the allowed amount — which determines reimbursement — by 25 percent for services provided by PhD-level psychologists and by 35 percent for masters-level therapists. This violated parity laws because United applied these reductions to psychotherapy across the board, but for medical treatments it applied similar restrictions only in limited circumstances.

2) Algorithms for Effective Reporting and Treatment (ALERT) program

United employed arbitrary thresholds to trigger utilization review of psychotherapy, which often led to denials of coverage when providers could not justify continued treatment after 20 sessions. Members who received these denials had to choose between figuring out how to pay hundreds, or even thousands, of dollars for continued care, and abruptly ending necessary treatment. United denied thousands of New Yorkers’ psychotherapy claims pursuant to ALERT, even during the COVID-19 pandemic. These denials violated parity laws because United subjected all outpatient behavioral health psychotherapy to outlier management, but it employed this treatment limitation only to a handful of medical/surgical services.

United’s illegal and discriminatory practices have impeded access to behavioral health services for more than half a million New Yorkers with fully-insured United health plans and many others with self-insured private health plans administered by the company.  

Under the agreements, United will stop applying the Reimbursement Penalty and will not employ a new, similar policy in New York for at least two years. United will also discontinue applying the ALERT program — and will cease issuing denials — for psychotherapy in New York, and will not implement a new outlier management program until at least 2023.