The Delaware Department of Insurance announced a follow-up Mental Health Parity and Addiction Equity Act examination of UnitedHealthcare Insurance Company and assessed a penalty of $450,000 for substantive findings, including repeated issues. The investigation also included reviews of complaint and grievance handling, policyholder services, claims, utilization review, medical necessity criteria, pharmacy review, and oversight of contracted Pharmacy Benefit Managers.
Mental Health Parity laws, existing at both state and federal levels, aim to eliminate coverage discrimination between policyholders seeking mental illness or substance abuse care and those seeking physical care. Insurance Commissioner Trinidad Navarro stated that the comprehensive re-examination will result in much-needed corrections in insurer activity. Delaware insurers have been assessed a total of $2.11 million since enforcement of Mental Health Parity began.
Violations found in policies and practices during the examination revolved around lack of parity between coverage for procedures and medications, and for preauthorization requirements. Improper application of Step-Therapy Protocol exceptions, misapplication of non-formulary and formulary drug definitions, and improper application of prior authorization for medication-assisted treatment were documented. UnitedHealthcare applied a broader definition of Specialty Drug than Delaware Code authorizes, and its automated prescription drug processing did not contain mental health drugs. The carrier failed to use the full set of American Society of Addiction Medicine (ASAM) criteria to provide unlimited medically necessary coverage for treatment.
The examination reviewed activity over a 24-month period. Some violations were cited in prior examinations, enhancing the penalty level. Additional findings included noncompliance with arbitration and appeal acknowledgement timelines, failure to complete speedy review of grievances, and failure to process clean claims within 30 days of receipt. Positive findings of compliance were noted in management of Pharmacy Benefit Manager and Third-Party Administrator relationships.
This article is an AI-assisted summary. All facts and figures are drawn from the original report: https://news.delaware.gov/2025/09/17/450k-in-mental-health-parity-penalties-issued-to-unitedhealthcare/