US Department of Labor, Kaiser Foundation Health Plan reach settlement to reform insurer’s practices on mental health, substance use disorder care

SAN FRANCISCO – The U.S. Department of Labor today announced a settlement with Kaiser Foundation Health Plan Inc. to resolve multiple investigations into the company’s failure to provide timely and appropriate access to mental health and substance use disorder services. 

The settlement between the department’s Employee Benefits Security Administration and Kaiser affects millions of members in California who receive coverage through their employer and sets up a claims process for covered members to seek reimbursement for certain out-of-network expenses. 

The agreement resolves allegations that Kaiser did not maintain adequate provider networks for mental health and substance use disorder care and used patient responses to questionnaires to improperly prevent patients from receiving care. As a result, many members were unable to access in-network mental health or substance use disorder care and were forced to seek care outside Kaiser’s network, often at higher out-of-pocket costs.

Under the settlement agreement, Kaiser will pay at least $28,323,219 for costs its members incurred when seeking out-of-network mental health and substance use disorder services. Kaiser will also pay a $2,832,321 penalty to the federal government.

In addition to these payments, Kaiser agreed to reform company policies and practices to improve access to mental health and substance use disorder care. These reforms include steps to reduce appointment wait times, improve care review processes to ensure members receive medically necessary care, and monitor network adequacy to ensure members have access to appropriate mental health and substance use disorder providers and facilities. 

As part of the settlement, Kaiser has provided notices to members in California who participated in the plan after Jan. 1, 2021, and were likely to have paid for out-of-network mental health and substance use disorder services after trying to obtain in-network services to let them know they may be eligible for reimbursement. 

Learn more about the settlement or how to file a claim by visiting the settlement website: www.outofnetworkhealthclaims.com, or calling Kaiser at 1-877-684-4129.

If you or someone you know is having difficulty finding an available mental health provider in your network, call EBSA toll-free at 866-444-3272 or visit askebsa.dol.gov.