Favorable Mental Health Parity Ruling Increases Access to Care
We just received this breaking news update from our friends at DBSA (Depression Bipolar Support Alliance)
“The medical necessity clauses found in insurance plans have been a barrier to accessing mental health care for many plan subscribers. Now because of a landmark court ruling in California, the largest managed behavioral health provider in the country can no longer hide behind medical necessity language to deny mental health and substance use care.
In a landmark ruling today in a nationwide class action suit, the United States District Court for the Northern District of California held that United Behavioral Health (“UBH/Optum”), illegally denied mental health and substance use coverage based on flawed medical necessity criteria.
Court Puts Patients First
The federal court found UBH developed restrictive medical necessity criteria with which it systematically denied outpatient, intensive outpatient, and residential treatment. Specifically, the federal court found that UBH’s internal guidelines limited coverage to “acute” care, in disregard of highly prevalent, chronic, and co-occurring disorders requiring greater treatment intensity and/or duration. The court was particularly troubled by UBH’s lack of coverage criteria specific to children and adolescents.
In his detailed ruling, Chief Magistrate Judge Joseph Spero found the following to be the generally accepted standards for behavioral healthcare from which UBH’s guidelines deviated:
- Effective treatment requires treatment of the individual’s underlying condition and is not limited to alleviation of the individual’s current symptoms;
- Effective treatment requires treatment of co-occurring behavioral health disorders and/or medical conditions in a coordinated manner that considers the interactions of the disorders and conditions and their implications for determining the appropriate level of care;
- Treatment for mental health should be received at the least intensive and restrictive level of care that is safe and effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions;
- Duration of treatment for behavioral health disorders is based on the individual needs of the patient; there is no specific limit on the duration of such treatment;
- Level of care for patients with mental health should be made on the basis of a multidimensional assessment that takes into account a wide variety of information about the patient.
Although the Mental Health Parity and Addiction Equity Act of 2008 requires parity for mental health and substance use benefits, insurers are permitted to evaluate claims for medical necessity. By applying internal guidelines or medical necessity criteria, however, insurers can easily circumvent parity and prevent patients from receiving the type and amount of care they actually need. The consequences to patients can be devastating.
Today’s ruling stems from two consolidated class actions brought under the Employee Retirement Income Security Act of 1974 (“ERISA”) in 2014. While the certified classes encompass tens of thousands of ERISA insureds, non-ERISA insureds (such as governmental employees) adversely impacted by UBH’s defective guidelines must rely on state and federal regulators to intervene on their behalf.”
Please forward to colleagues, family, and friends to assist in this grassroots effort to make our voices heard. To continue to receive communications about issues that support access to quality mental health care from DBSA, register here.