Centene Ambetter Health Insurance Plans Performance RICO Class Action

Ambetter health insurance plans are sold on the exchanges established by the Affordable Care Act (ACA). This class action brings suit against those who provide the plans, including Centene Corporation, Centene Management Company, LLC, and Celtic Insurance Company, alleging they sell fraudulent health insurance policies and have violated the Racketeer Influenced and Corrupt Organizations (RICO) Act, among other things.

A federal class and a number of state subclasses have been defined for this action:

• The Federal Law Class is all persons who paid premiums for an Ambetter brand health insurance plan, between August 5, 2018 and the present, while living in Arizona, Arkansas, California, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, or Washington.
• The State Law Subclasses include subclasses for the states of Arizona, California, Florida, Illinois, Kentucky, Nebraska, Nevada, New Jersey, New Mexico, North Carolina, Pennsylvania, and Washington, and consist of all persons who paid premiums for an Ambetter brand health insurance plan, between August 5, 2018 and the present, while living in the respective state.

Centene, the complaint says, is the largest provider of health insurance plans on the ACA exchanges, offering plans for some 15 million people in twenty-six states under the brand name Ambetter. According to the complaint, Ambetter plans are targeted primarily at low-income persons who cycle in and out of Medicaid as their incomes fluctuate.

Most of the plans—90%, the complaint claims—are “silver” level plans, for which the federal government pays a share of the monthly premiums, and the insureds supposedly have lower deductibles, copayments, and out-of-pocket costs.

But the complaint alleges that the Ambetter plans “are simply false and are often just copies of physician directories from other sources” so that those who sign up for the plans have difficulty finding providers who are in-network and who accept Ambetter insurance. The complaint claims that this results in delays in medical treatment, long wait times, travel time to see providers who are far away, and paying for out-of-network services when they cannot find in-network providers for certain purposes.

“In addition,” the complaint alleges, “Ambetter plans routinely refuse to pay for medical services and medications that the plan purportedly covers.” It claims that providers have sued Centene and its other companies many times, and that many providers now refuse to accept Ambetter insurance for this reason, making it even harder to find in-network providers.

This leads to even more problems for plan members as well, the complaint alleges, because they may become stuck with the bill Ambetter refuses to pay “and will certainly have to pay for the prescription out-of-pocket.”

The complaint asserts that “the plans don’t deliver what they promise and fail to satisfy minimum requirements imposed by the ACA and state laws.”

Article Type: Lawsuit
Topic: RICO
Tags: Health Insurance, Inaccurate Information about Provider Network, Incomplete payment of benefits due, Payment of Promised Benefits or Subsidies, RICO laws, Unfair Health Plans