Harrisburg, Pa. — An insurance company has been ordered to pay more than a half million dollar penalty in Pennsylvania for its mental health coverage failures, officials announced.
The Pennsylvania Insurance Department (PID) recently announced the results of an audit of Aetna’s health insurance company that found several violations that negatively impacted policyholders.
As a result, Aetna, must pay a $550,000 penalty, fix its practices, and repay affected Pennsylvanians. PID’s market conduct exams hold insurance companies accountable and ensure Pennsylvania families receive the coverage they are promised.
“A few years ago, Governor Shapiro tasked PID with making mental health parity a true reality for Pennsylvanians,” said Pennsylvania Insurance Commissioner Michael Humphreys. “Today’s announcement is another giant step toward that ultimate goal and represents just one of the many ways PID protects consumers. Our front-end compliance reviews and back-end enforcement is among the most robust in the country, and we will continue to enforce Pennsylvania laws and regulations to the fullest extent of our statutory authority.”
The Aetna exam covers the period from Oct. 1, 2021, through Dec. 31, 2022. A consent order was signed in January 2026. The full report can be found on PID’s website.
PID’s exam found:
Incomplete claims files, especially for Autism Spectrum Disorder (ASD) services;Delays in approving or denying claims and failure to explain those delays;Improper claim denials due to poor internal communication about prior approvals and other insurance coverage;Failure to clearly explain member cost-sharing for ASD services; andViolations of mental health parity laws, including incorrect or incomplete analysis and application of benefit limits.
PID also found broader “universe” violations. These included flawed methods for reviewing mental health parity compliance and failure to clearly list cost-sharing for ASD services in most plans. The company also confirmed it was not sending required claim delay letters during the exam period.
Under the consent order, Aetna must:
Reprocess claims that were handled incorrectly and pay members what they are owed, with interest;Improve internal systems to make sure claims are processed correctly and on time;Clearly explain cost-sharing in benefit documents;Fix denial letters so they clearly explain why services were denied, especially for Applied Behavior Analysis services for ASD; andReprocess claims that did not meet mental health parity requirements and provide proof of repayment to PID.
Aetna must complete most of these corrective actions within 12 months, with regular reports to PID.
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