Source: http://www.state.me.us/pfr/insurance/consent_agreements/2000-2004/012504.htm
Timestamp: 2014-03-09 17:37:33
Document Index: 527383653

Matched Legal Cases: ['§ 9053', '§ 12', '§ 2677', '§ 2843', '§ 2677', '§ 2843', '§ 2677', '§ 2843', '§ 402', '§ 408']

Docket No. INS 01-2504
This document is a Consent Agreement, authorized by 5 M.R.S.A. § 9053(2) and 24-A M.R.S.A. § 12-A(1), and is entered into by United Behavioral Health (hereafter also UBH) and the Superintendent of the Maine Bureau of Insurance (hereafter also the Superintendent). Its purpose is to resolve, without resort to an adjudicatory proceeding, UBH’s violations of 24-A M.R.S.A. § 2677(1), which establishes for preferred provider arrangements a maximum differential between benefits payable to preferred providers and benefits to non-preferred providers; and of 24-A M.R.S.A. § 2843(5-C)(B)(1), requiring parity between the level of mental illness benefits and the level of physical illness benefits.
From April 1, 1994, UBH has been a Maine licensed utilization review entity (URE), License # URF38961. At all times herein, UBH acted as the URE and the administrator for United HealthCare Insurance Company’s (UHC’s) "Employee Assistance Plan," a preferred provider contract covering mental health benefits
On December 21, 1999, the Bureau received complaint #2000506777 from Consumer, an enrollee under the UHC plan. Consumer complained because UBH refused to authorize payment of more than 50% of charges for four psychiatric therapy sessions rendered by a non-preferred provider to Consumer from August to December 1999. On January 5, 2000, the Bureau intervened on Consumer’s behalf to investigate her complaint of inadequate payments to the therapist. In initially denying Consumer’s claim for higher payment, UBH did not submit to her a written explanation of benefits (EOB). The Bureau requested an EOB, and UBH prepared and sent an explanation dated February 16, 2000. The EOB shows that the non-participating therapist charged $70 per session, and that UBH authorized 50% of the charge for each session.
An insurer or administrator who makes a preferred provider arrangement available shall provide for payment of covered health care services rendered by providers who are not preferred providers.
Benefit level…. [T]he benefit level differential between services rendered by preferred providers and non-preferred providers may not exceed 20% of the allowable charge for the service rendered.
The benefits schedule in the UHC plan pays 80% of covered psychiatric services rendered by preferred providers, and 50% of charges for covered services from non-preferred providers. This schedule thus creates a 30% differential as between preferred and non-preferred providers, exceeding the 20% spread allowed by § 2677(1).
For policies, contracts or certificates covering 21or more employees, 24-A M.R.S.A. § 2843(5-C)(B)(1) requires that insurers provide benefits for mental illnesses that are no less than benefits payable under a concurrent plan insuring the individual for physical illness expenses:
The [contracts] must provide benefits for the treatment and diagnosis of mental illnesses under terms and conditions that are no less extensive than the benefits provided for medical treatment for physical illnesses.
During August through December 1999, when Consumer received the subject mental health treatment for which UHC paid 50% of covered charges, her medical insurance plan then in effect paid 70% of non-network treatment of physical illness.
As described in paragraphs 3, 5, 6 and 7 above, UBH violated 24-A M.R.S.A. § 2677(1) by authorizing payment to Consumer’s non-preferred provider of only 50% of the psychiatric charges at issue, in excess of the allowable 20% differential between preferred provider and non-preferred provider benefits. As described in paragraphs 8 and 9 above, UBH violated 24-A M.R.S.A. § 2843(5-C)(B)(1) by authorizing payment of mental health benefits under the UHC plan to non-preferred providers at 50% of charges, sums not in parity with the 70% benefits paid to out-of-network providers under Consumer’s separate coverage for physical illnesses.
COVENANTS A formal hearing in this complaint proceeding is waived and no appeal will be taken. This Consent Agreement is an enforceable agency action within the meaning of the Maine Administrative Procedure Act.
At the time of executing this Agreement, UBH shall pay to the Maine Bureau of Insurance a penalty in the amount of $3,000 drawn to the Maine State Treasurer.
In consideration of UBH’s execution of and compliance with the terms of this Consent Agreement, the Superintendent agrees to forgo pursuing any disciplinary measure or other civil sanction for the violations described above other than those agreed to herein. MISCELLANEOUS
UBH understands and acknowledges that this Agreement will constitute a public record within the meaning of 1 M.R.S.A. § 402, will be available for public inspection and copying as provided by 1 M.R.S.A. § 408, and will be reported to the NAIC "RIRS" database.
UBH was informed of the right to its own counsel before executing this Agreement.
Nothing herein shall prohibit the Superintendent of Insurance from seeking an order to enforce this Consent Agreement, or from seeking additional sanctions in the event UBH does not comply with the above terms, or in the event the Superintendent receives evidence that further legal action is necessary for the protection of Maine consumers. FOR UNITED BEHAVORIAL HEALTH Dated:______________, 2001