Illinois fines Celtic Insurance $1.25M

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 alleges 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 they do for medical or surgical care. Illinois law expands on that federal law.

Specifically, the department says Celtic required prior authorization for all substance use disorder claims. Prior authorization is when a patient must get an insurance company’s approval for coverage of a treatment or medication before the patient can get it. It’s a requirement that many have criticized as creating barriers to care.

The company also allegedly required prior authorization to get medications for ADHD, depression, drug overdose and the treatment of opioid withdrawal symptoms, among others, according to the department.

The department says that Celtic limited the quantities of anti-anxiety, antipsychotic, smoking cessation, schizophrenia, addiction treatment and HIV/AIDS medications that it would 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 workers who have contracted with an insurance company to provide care to its members. Celtic did not provide members with an up-to-date, accurate directory of its in-network health care providers, according to the department.

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

The findings came from a market conduct examination conducted by the Illinois Department of Insurance covering the period of 2018 to 2020. Such examinations, conducted periodically, examine an insurer’s compliance with laws and regulations meant to protect consumers.

Celtic and Centene are also facing 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.

The consumers, who are seeking class-action status for the lawsuit, allege the companies kept incorrect lists of provider networks, making it difficult for them to find treatment and care. The lawsuit also alleges that Ambetter plans “routinely refuse to pay for medical services and medications that the plan purportedly covers.”

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

“This lawsuit is merely one more attack on the Health Insurance Marketplace and the ACA itself,” Centene said in the statement. “Centene will fight this lawsuit vigorously and will continue to uphold the important purpose of the (Affordable Care Act) to improve the health of our communities, one person at a time.”

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