RICHMOND 鈥 One of the state鈥檚 biggest health insurers, Healthcare, treated claims for coverage of autism and transgender care unfairly, a review found.
The bureau also found Cigna was improperly lenient with claims for outpatient physical therapy, occupational therapy, and chiropractic medical or surgical benefits.
In addition, the bureau said Cigna used unfair methods to determine what care is subject to prior authorization, concurrent review, and retrospective review, as well as for how it classifies outpatient services.
The bureau鈥檚 101-page market conduct examination also found Cigna鈥檚 internal monitoring to ensure coverage is not improperly restrictive for seven other services was incomplete.
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In response, Cigna agreed to a 13-point corrective action plan, and paid $330,000 to settle the bureau鈥檚 belief that it violated state law and regulation.
It did so 鈥渟olely for the purpose of a settlement and does not constitute, nor should it be construed as, an admission of any violation of law,鈥 Katie Stewart, the company鈥檚 regional vice president, said in a written statement to the bureau.
The company did not respond immediately to a request for further comment.
Transgender care
The issues involved coverage for two non-medical therapies for autism and treatment for transgender teenagers.
Insurers had for years resisted paying for 鈥渁pplied behavior analysis鈥, a non-medical therapy for autism treatment, until the General Assembly in 2011 passed a law requiring coverage.
Transgender care has become a political flashpoint, although the bureau examination started in 2022. It covered records through early 2024, well before President Donald Trump鈥檚 intensified targeting of transgender people during the election campaign.
In Cigna鈥檚 case, the issue involved a mastectomy for a teenager, and the company鈥檚 requirement for two separate letters of support, each from an independent mental health provider experienced in adolescent mental health and the diagnosis and treatment of childhood gender dysphoria, to show that coverage is medically necessary.
But the 鈥淪tandards of Care for the Health of Transgender and Gender Diverse People鈥 that the World Professional Association for Transgender Health published says a single letter from a multidisciplinary team should determine medical necessity. It says such a team should include a mental health provider, an endocrinologist, a primary care physician, and others.
The bureau said that extra letter from a second mental health clinician specializing in childhood gender dysphoria 鈥 the psychological distress when assigned sex at birth does not match an individual鈥檚 gender identity 鈥 is more restrictive than the usual medical standard, and so is unfairly discriminatory.
Cigna said earlier guidelines from the transgender health association had required two letters, and that without more evidence it believes it would be unsafe to change from the two letters requirement.
The bureau said the insurer had misread that earlier guideline which specifically said only one letter from a qualified mental health professional was needed for mastectomy or chest reconstruction.
Loleta Keith, Cigna鈥檚 senior adviser for legal compliance, wrote in response: 鈥淥ur treatment decisions are guided by the best available evidence, and are intended to promote access to care while minimizing long-term untoward consequences.
鈥淚t is well-documented in the scientific literature ... that persistence of an incongruous gender identity is variable between childhood and adulthood, with some studies reporting a less than 10% persistence of a trans identity into adulthood,鈥 Keith added, citing two articles from 2008 and one from 2023.
The bureau said it looked up those articles, and noted that they appeared to rely on outdated research in some cases dating back as far as 1948.
In the end, Cigna agreed to change its requirement, saying it still disagreed with the bureau and did not consider it unduly burdensome to ask for two letters.
Autism coverage
On autism, the company accepted the bureau鈥檚 corrective action to change its practice without contesting it.
The bureau found Cigna鈥檚 coverage for applied behavior analysis and intensive behavioral intervention set stricter standards for paying claims than the Code of Virginia dictates. These are therapies that focus on encouraging behavior that helps people with autism communicate, improve focus and social skills and avoid problem behaviors.
Specifically, Cigna required that 鈥渕eaningful and measurable improvement is expected from the therapy鈥 while state law says treatment must 鈥渁chieve or maintain maximum functional capacity in performing daily activities.鈥
That state standard is essentially the same as that of the national Council of Autism Service Providers.
