Really, Aetna? DMHC Orders Aetna to Stop Wrongfully Denying Payment for Emergency Medical Services

This just in from The California Department of Managed Health Care:

[DMHC] has ordered Aetna Health of California, Inc. to stop using the plan’s national standard to deny payment for emergency room claims. This practice has resulted in Aetna wrongfully denying members’ emergency room claims as the plan should be applying California’s broader standard to approve emergency room services.

The Department has also fined Aetna $500,000 for repeatedly failing to apply California law and failing to implement corrective actions to correct this problem. Aetna has repeatedly agreed to follow California’s standard for reimbursing emergency room claims but has continued to use its national standard, resulting in many wrongful denials of emergency room claims.

California law requires a health plan to pay for emergency medical services unless it is in possession of evidence to show that either the emergency medical services were never performed or the enrollee did not require emergency medical services and reasonably should have known that an emergency did not exist.

The Department has previously taken enforcement action against Aetna for improperly denying coverage for enrollees’ emergency medical services. Aetna entered into settlement agreements with the DMHC in 2015 and 2016 and paid $135,000 in fines. Aetna also agreed to Corrective Action Plans requiring training for employees handling claims for emergency services and reimbursement for emergency services based on the California standard.

Despite the enforcement actions taken against the plan to correct its deficiencies, the DMHC Help Center received four complaints in 2018 and 2019 showing that the plan had wrongfully denied emergency room claims based on the incorrect standard. The DMHC then conducted a medical survey of the plan’s operations and reviewed a sample of the plan’s denials of emergency medical services. In 2019, the Department’s final survey report concluded that 93 percent of the sampled claims were wrongfully denied. The Department also reviewed Aetna’s commercial emergency medical services denial template for HMOs and determined that the templates did not follow California law.

If a health plan denies payment for emergency services, enrollees should file a grievance with their health plan and include a copy of the bill. Their health plan will review the grievance and should ensure the plan is following the California standard. If the consumer does not agree with their health plan’s response or if the plan takes more than 30 days to fix the problem, they can file a complaint with the DMHC Help Center at  or 1-888-466-2219.

Great Business Advice at

Cal Broker contributor Alan Katz has a two-part business planning story up on our site right now. Check out Now Is The Time to Write a Business Plan and Business Planning Part 2: Keep It Simple. Thanks for your insight, Alan!

Be a Sport, Send Us Your Photo Too!

This lovely reader is Doris Ford, owner and CEO of Ford Benefits Group in Azusa (Northeast of Los Angeles). She’ll be featured in the CalBroker GPS column of an upcoming issue of California Broker magazine. Send your photo reading Cal Broker to and you could make it in too! Don’t forget to tell us about yourself and what you like to read! Thanks, Doris!


Colonial Life Survey: Benefits Enrollment Rushed

A new Colonial Life study finds nearly 3 in 4 consumers (73%) spend less than an hour each year evaluating their benefit options. According to a Colonial Life study of 1,200 U.S. consumers, 73% spend less than an hour and 41% invest less than 30 minutes considering their benefits at enrollment time. Surprisingly — or maybe not? — those who are the least confident in their knowledge of benefits are the biggest rushers. And there are a lot of those types: Nearly 90% of consumers reported not understanding their benefits at all. Looks like there are plenty of opportunities for education, employee benefits folks!

Do You Know Some Outstanding Benefits Folks?

Nominations are now open for Employee Benefit News’ annual Benny Awards, which recognize four individuals for excellence in the employee benefits/human resources field, with particular focus on how they have navigated employers and clients through the pandemic. Act now because the deadline is Aug. 28. You must fill out this online form to be considered.


Ensight Partners with Proformex

San Diego-based Ensight, a life and annuity digital sales acceleration platform for insurance carriers, distributors and financial professionals, announced it has partnered with Proformex, an inforce management platform. The company will integrate Ensight’s quoting API platform to enhance Proformex’s intelligent inforce policy monitoring, which provides insurance agents and financial advisors better oversight and visibility into inforce policy contract performance. The partnership is part of Proformex’s strategy to simplify the complexity and challenges of managing inforce business at scale, while providing actionable insights for its customers. Integrating the Ensight Quoting API aims to enable Proformex customers to evaluate potential protection options for their clients during the policy review process without ever leaving the Proformex platform.


Well, We Love Facts

Adam Fein at Drug Channels has a great post about prescription drug trends in the wake of the pandemic. He also addresses the issue of getting presccription drugs through the United States Postal Service. From  Fein:

As I told The New York Times last week, the number of patients relying on mail for their prescriptions is far from trivial. But the vast majority of patients get their prescriptions through retail pharmacies or by mail from carriers other than the USPS. And let’s not forget than 9 out of 10 Americans live within one mile of a community retail pharmacy location.


VSP Vision Care Partners with Employee Navigator  


 VSP Vision Care announced a partnership with Employee Navigator, a provider of benefits and HR solutions for brokers. The partnership aims to make it easier for brokers and HR administrators to manage and administer their employee benefits. VSP says the ability to automate previously tedious tasks will allow brokers to offer a streamlined experience to their customers, reducing their compliance burden and enabling them to more easily access benefit selections.


Long Term Care Providers Facing Financial Hardship Due To COVID

The American Health Care Association and National Center for Assisted Living released national surveys conducted on August 8-10, 2020, of long term care providers which showcase the increased costs and financial hardship nursing homes and assisted living communities are facing in response to COVID-19. Check out the full survey reports: Nursing Homes/Assisted Living Communities


Congrats NAIFA Award Winners!

NAIFA-Los Angeles won the GOLD Excellence in Achievement Award from NAIFA-California, NAIFA-Greater Foothills won SILVER and Greater Bay Area took home BRONZE. Fresno received the affiliate GOLD.  A hearty congratulations to all!

Petersen Congratulates Dedicated Employees

Our friends at Valencia-based Petersen International Underwriters wish to congratulate six of their dedicated crew as their September anniversaries approach. The employees include:

Lori Boggs, RVP based in Tampa Florida celebrates her 4th year with PIU. Lori works with numerous producers mainly on the East Coast.

Katie Bonilla and Kim Crocker both celebrate their 5th anniversary at PIU. Both work at the home office in Valencia. Katie works in billing and Kim in underwriting.

Kelli Yacovone, pictured above left, celebrates her 27th year at PIU. Kelli is the team leader of the policy issue department.

Terie Garcia, pictured above right, has been with PIU for 35 years! Terie is a team leader in underwriting.

Thank you for serving the industry so well!


  • LAAHU’s Zoom Happy Hour is today following the first day of the California Statewide Medicare Expo!
  • California Statewide Medicare Expo, Virtual, Aug 26-27 — Today and Tomorrow!

Ten local California Association of Health Underwriters chapters are hosting California Statewide Medicare Expo. More than 100 sessions and opportunities for certifications and CE. Make sure you visit Cal Broker’s booth!

  • NAIFA-Los Angeles Events

Thursday August 27, 2020: Life Insurance Awareness webinar with 4 great speakers. Info and registration here.

Friday September 25, 2020: Health Forum. Info and registration here.
  • National African-American Insurance Association (NAAIA) Events
See NAAIA event offerings here.
  • The Senior Summit, Virtual, Sept 1-3

A collaboration of Inland Empire, Orange County and San Diego Associations of Health Underwriters. Certifications, product trainings, CEs, guest speakers, industry experts, as well as a virtual exhibit hall and more! Price: $49 AHU Member or Non-Member (3 Day Admission). Deadline to Register: August 28. Info and registration here.

  • CAHU Summit, Virtual, Oct 6-7- Moving Boldly Into Our Future

Keynote speaker will be Joe Buzzello, a life-long entrepreneur, author and a master salesperson and organizational leader. Sponsorship info here. Register here.

  • IICF Foundation Women in Insurance Regional Forums Rescheduled

Insurance Industry Charitable Foundation has rescheduled the Women in Insurance Regional Forums:

Chicago: October 14
New York: October 26

Los Angeles: October 30
Dallas: November 17
More info at IICF’s website.
  • IICF Inclusion in Insurance Forum, Virtual, October 27 – 29
The Insurance Industry Charitable Foundation will convene insurance professionals, C-Suite executives, D&I leaders and other innovators for the IICF Inclusion in Insurance Foruman action-oriented program with a focus on the future of work in the insurance industry. Gain insights and plans for acting on inclusion, diversity and innovation initiatives from respected leaders representing the industry, academia and other areas of business. Each virtual session will run approximately 2-1/2 hours, starting at 9a.m. Pacific.Register here.
  • CAHU Women’s Leadership Summit will now be April 7-9, 2021!

The latest news from CAHU’s WLS committee is that the CAHU Women’s Leadership Summit will now take place April 7 –9, 2021, at Green Valley Ranch in Las Vegas.  Questions should be emailed to

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