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EmblemHealth agrees to refunds, fine over coverage violations

By Shaun Zinck | Mar 14, 2015

New York Attorney General Eric Schneiderman said the state and insurer EmblemHealth have come to an agreement in which the insurer will reimburse affected policyholders and pay a fine over coverage violations. | New York Attorney General

Insurer EmblemHealth will expand its preventive-care services in an agreement last week with the New York Attorney General’s Office, Attorney General Eric Schneiderman said.

EmblemHealth will be required to cover anesthesiology services in connection with an in-network preventive colonoscopy. The agreement also prevents the business from cost-sharing with members, which is part of the Patient Protection and Affordable Care Act.

“Preventative screening procedures are critical to improving the health of New Yorkers, and today’s agreement will help ensure that more people are getting important life-saving care,” Schneiderman said. “My office will continue to verify that health insurance companies are following the law so that we can avoid the needless patient suffering and high-cost care involved with advanced illnesses.”

Colonoscopies can be considered preventive care, and anesthesia is necessary to administer the services. Under the Affordable Care Act, anesthesia services should be covered without member cost-sharing. Schneiderman said only some Emblem plans were structured to follow the law, but even they didn’t remove the cost-sharing for anesthesia services.

EmblemHealth also will send refund checks to members of certain plans who paid a co-payment, co-insurance payment or deductible for the anesthesiology services. The total reimbursements will be about $400,000, and Emblem will train employees on the law and pay a penalty, Schneiderman said.

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