May 19, 2015

Gov. Nixon announces $4.5 million settlement with Aetna after company failed to provide required autism coverage

If Aetna violates settlement terms, Missouri Department of Insurance will be able to suspend certificate to do business in state

Springfield, MO - Gov. Jay Nixon today announced that the State of Missouri has reached a $4.5 million settlement with Aetna Life Insurance Company and Aetna Health Insurance Company (referred to collectively as Aetna in this news release) after the companies failed to provide coverage for the diagnosis and treatment of autism spectrum disorders. 

The settlement - which includes Missouri's largest fine ever for insurance law violations - also allows the Missouri Department of Insurance to suspend those companies from doing business in the state for up to one year, if they violate the agreement during a three-year monitoring period.

"The landmark law requiring insurance companies to cover autism spectrum disorders was a great victory for many thousands of Missouri kids and their families," Gov. Nixon said, in announcing the agreement at the Burrell Autism Center in Springfield. "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."

In 2010, Gov. Nixon spearheaded the bi-partisan effort to pass the law mandating the coverage of autism diagnosis and treatment. For the first time, insurance companies were required to cover one of the most highly effective types of therapy, Applied Behavioral Analysis, or ABA. While effective, the cost of ABA can exceed tens of thousands of dollars a year, making insurance coverage necessary for most families.   

Today's settlement, in which Aetna admitted it failed to offer autism coverage in some cases, includes a $4.5 million fine and the requirement that Aetna subject itself to a corrective action plan and three years of monitoring by the Department of Insurance. A portion of the fine, $1.5 million, will be suspended if Aetna complies with the settlement agreement.

In 2012, the two Aetna companies also admitted to violating the autism mandate and paid a $1.5 million fine under a settlement agreement with the Department of Insurance. The companies were required to undertake a full and complete audit to ensure compliance with all Missouri insurance mandates. Aetna admits it did not undertake that full compliance audit.

"Aetna violated Missouri law and withheld state mandated benefits from Missouri families," said Missouri Department of Insurance Director John M. Huff, who also was at today's announcement. "Insurers must provide Missourians with benefits required under Missouri law and I will use the full extent of my regulatory authority to ensure they receive them. Additionally, these companies failed to comply with previous orders issued by me.  This is a serious compliance issue that requires serious regulatory consequences."

"When an insurance company chooses to do business in our state, they agree to follow our laws," the Governor said. "These were serious violations that deserved serious punishment - and that's what Aetna received."

Under the Missouri Constitution, civil fines go to the School Fund. The imposition of the suspension will be held in abeyance, pending the companies' compliance with the terms of the settlement agreement during the three-year monitoring period.