EBSA is the Department of Labor office that enforces Title I of ERISA for private-sector benefit plans; by statute (ERISA Sec. 504 & 506) it may investigate civil and, with DOJ coordination, criminal violations, require disclosures, obtain documents (including PHI under HIPAAs health‑oversight authority), negotiate settlements or refer cases for litigation, and seek monetary relief and compliance remedies.
According to the Labor release, Kaiser sent notices to California employer‑plan members who participated after Jan. 1, 2021 and who were “likely to have paid for out‑of‑network mental health and substance use disorder services after trying to obtain in‑network services.” Those members must submit claims through the settlement claims process (via the claims website or phone) to seek reimbursement.
The $28,323,219 is earmarked to reimburse members for out‑of‑network mental health and substance use disorder (behavioral/behavioral‑health) services they paid for because they couldn’t obtain timely in‑network care. The Labor release limits affected members to those covered by Kaiser employer plans in California who participated after Jan. 1, 2021; the settlement documents/claim notices give the operative claim window and eligible service types (behavioral health and SUD outpatient/inpatient, emergency, and related services) on the claims site.
The DOL said investigators found Kaiser used members’ answers to screening or intake questionnaires as a basis to deny or delay access to in‑network mental‑health and substance‑use disorder care. That refers to behavioral‑health screening/intake forms and utilization/care‑review questionnaires used in care‑coordination and review that staffing or policy then used to limit authorizations or referrals — a practice EBSA alleged improperly prevented members from receiving timely, medically‑necessary in‑network care.
The settlement requires Kaiser to change policies/practices (reduce wait times, improve care‑review, monitor network adequacy) and EBSA will monitor compliance through the settlement terms and claims administrator reports; EBSA enforces ERISA by oversight, requiring reporting, demanding remedial measures in consent agreements, and can compel further relief or litigation if Kaiser doesn’t comply.
The announced agreement specifically affects California members covered through employer plans (Kaiser provided notices to California members who participated after Jan. 1, 2021). EBSA enforcement can and does investigate ERISA‑covered plans nationally, so similar investigations or settlements could apply to Kaiser plans in other states if EBSA or state regulators find similar problems.
Claims will be handled through the settlement administrator (the site listed in the DOL release: www.outofnetworkhealthclaims.com) — Kaiser provides a phone number in the release as well. Members who need help can contact the claims website/administrator or call EBSA toll‑free at 866‑444‑3272 or use askebsa.dol.gov for assistance.