Attorney General James and U.S. Department of Labor Deliver $14 Million to Consumers Who Were Denied Mental Health Care Coverage

Press Release

NY Attorney General

Posted 12 August 21

New York Attorney General Letitia James and the U.S. Department of Labor (USDOL) today announced landmark agreements with UnitedHealthcare (United), the nation’s largest health insurer, to resolve allegations that United unlawfully denied health care coverage for mental health and substance use disorder treatment for thousands of Americans. As a result of these agreements, United will pay approximately $14.3 million in restitution to consumers affected by the policies, including $9 million to more than 20,000 New Yorkers with behavioral health conditions who received denials or reductions in reimbursement. New York and federal law requires health insurance plans to cover mental health and substance use disorder treatment the same way they cover physical health treatment. The agreements — which resolve investigations and litigation — address United’s policies that illegally limited coverage of outpatient psychotherapy, hindering access to these vital services for hundreds of thousands of New Yorkers for whom United administers behavioral health benefits. In addition to the payment to impacted consumers, United will lift the barriers it imposed and pay more than $2 million in penalties, with $1.3 million going to New York state.  

“In the shadow of the most devastating year for overdose deaths and in the face of growing mental health concerns due to the pandemic, access to this care is more critical than ever before,” said Attorney General James. “United’s denial of these vital services was both unlawful and dangerous — putting millions in harm’s way during the darkest of times. There must be no barrier for New Yorkers seeking health care of any kind, which is why I will always fight to protect and expand it. I thank Secretary Walsh for his partnership on this important matter.” 

“Protecting access to mental health and substance use disorder treatment is a priority for the Department of Labor and something I believe in strongly as a person in long-term recovery,” said U.S. Secretary of Labor Marty Walsh. “This settlement provides compensation for many people who were denied full benefits and equitable treatment. We appreciate Attorney General James and her office for their partnership in investigating, identifying, and remedying these violations.” 

New York’s behavioral health parity law — originally enacted as “Timothy’s Law” in 2006 — and the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) require insurance coverage for mental health and substance use disorder treatment to be no more restrictive than insurance coverage for physical health conditions. The agreements are the product of the first joint state-federal enforcement of these laws.  

The pressor is here.

Affordable treatment for mental illness and substance abuse gets harder to find

Jenny Gold
The Washington Post
Originally published 1 Dec 19

Here is an excerpt:

A report published by Milliman, a risk management and health-care consulting company, found that patients were dramatically more likely to resort to out-of-network providers for mental health and substance abuse treatment than for other conditions. The disparities have grown since Milliman published a similarly grim study two years ago.

The latest study examined the claims data of 37 million individuals with commercial preferred provider organization’s health insurance plans in all 50 states from 2013 to 2017.

Among the findings:

●People seeking inpatient care for behavioral health issues were 5.2 times more likely to be relegated to an out-of-network provider than for medical or surgical care in 2017, up from 2.8 times in 2013.

●For substance abuse treatment, the numbers were even worse: Treatment at an inpatient facility was 10 times more likely to be provided out-of-network — up from 4.7 times in 2013.

●In 2017, a child was 10 times more likely to go out-of-network for a behavioral health office visit than for a primary care office visit.

●Spending for all types of substance abuse treatment was just 0.9 percent of total health-care spending in 2017. Mental health treatment accounted for 2.4 percent of total spending.

In 2017, 70,237 Americans died of drug overdoses, and 47,173 from suicide, according to the Centers for Disease Control and Prevention. In 2018, nearly 20 percent of adults — more than 47 million people — experienced a mental illness, according to the National Alliance on Mental Illness.

“I thought maybe we would have seen some progress here. It’s very depressing to see that it’s actually gotten worse,” said Henry Harbin, former chief executive of Magellan Health, a managed behavioral health-care company, and adviser to the Bowman Family Foundation, which commissioned the report. “Employers and insurance plans need to quadruple their efforts.”

The info is here.

Holding Insurers Accountable for Parity in Coverage of Mental Health Treatment.

Paul S. Appelbaum and Joseph Parks
Psychiatric Services 
Originally posted 14 Nov 19

Despite a series of federal laws aimed at ensuring parity in insurance coverage of treatment for mental health and general health conditions, patients with mental disorders continue to face discrimination by insurers. This inequity is often due to overly restrictive utilization review criteria that fail to conform to accepted professional standards.

A recent class action challenge to the practices of the largest U.S. health insurer may represent an important step forward in judicial enforcement of parity laws.

Rejecting the insurer’s guidelines for coverage determinations as inconsistent with usual practices, the court enunciated eight principles that defined accepted standards of care.

In 2013, Natasha Wit, then 17 years old, was admitted to Monte Nido Vista, a residential treatment facility in California for women with eating disorders. At the time, she was said to be suffering from a severe eating disorder, with medical complications that included amenorrhea, adrenal and thyroid problems, vitamin deficiency, and gastrointestinal symptoms. She was also reported to be experiencing symptoms of depression and anxiety, obsessive-compulsive behaviors, and marked social isolation. Four days after admission, her insurer, United Behavioral Health (UBH), denied coverage for her stay on the basis that her “treatment does not meet the medical necessity criteria for residential mental health treatment per UBH Level of Care Guidelines for Residential Mental Health.” The reviewer suggested that she could safely be treated at a less restrictive level of care (1).

Ms. Wit’s difficulty in obtaining coverage from her health insurer for care that she and her treaters believed was medically necessary differed in only one respect from the similar experiences of thousands of patients around the country: her family was able to pay for the 2 months of residential treatment that UBH refused to cover.

The info is here.

Legal Promise Of Equal Mental Health Treatment Often Falls Short

Graison Dangor
Kaiser Health News
Originally pubished June 7, 2019

Here is an excerpt:

The laws have been partially successful. Insurers can no longer write policies that charge higher copays and deductibles for mental health care, nor can they set annual or lifetime limits on how much they will pay for it. But patient advocates say insurance companies still interpret mental health claims more stringently.

“Insurance companies can easily circumvent mental health parity mandates by imposing restrictive standards of medical necessity,” said Meiram Bendat, a lawyer leading a class-action lawsuit against a mental health subsidiary of UnitedHealthcare.

In a closely watched ruling, a federal court in March sided with Bendat and patients alleging the insurer was deliberately shortchanging mental health claims. Chief Magistrate Judge Joseph Spero of the U.S. District Court for the Northern District of California ruled that United Behavioral Health wrote its guidelines for treatment much more narrowly than common medical standards, covering only enough to stabilize patients “while ignoring the effective treatment of members’ underlying conditions.”

UnitedHealthcare works to “ensure our products meet the needs of our members and comply with state and federal law,” said spokeswoman Tracey Lempner.

Several studies, though, have found evidence of disparities in insurers’ decisions.

The info is here.

Wit et al. vs. United Behavioral Health and Alexander et al. vs. United Behavioral Health

U.S. Federal Court Finds United Healthcare Affiliate Illegally Denied Mental Health and Substance Use Coverage in Nationwide Class Action

• Landmark Case Challenges the Nation’s Largest Mental Health Insurance Company for Unlawful, Systematic Claims Denials – and Wins

• Groundbreaking Ruling Affects Certified Classes of Tens of Thousands of Patients, Including Thousands of Children and Teenagers 

• Judge Rules, “At every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”

In a landmark mental health ruling, a federal court held today that health insurance giant United Behavioral Health (UBH), which serves over 60 million members and is owned by UnitedHealth Group, used flawed internal guidelines to unlawfully deny mental health and substance use treatment for its insureds across the United States. The historic class action was filed by Psych-Appeal, Inc. and Zuckerman Spaeder LLP, and litigated in the U.S. District Court for the Northern District of California.

The federal court found that, to promote its own bottom line, UBH denied claims based on internally developed medical necessity criteria that were far more restrictive than generally accepted standards for behavioral health care. Specifically, the court found that UBH’s criteria were skewed to cover “acute” treatment, which is short-term or crisis-focused, and disregarded chronic or complex mental health conditions that often require ongoing care.

The court was particularly troubled by UBH’s lack of coverage criteria for children and adolescents, estimated to number in the thousands in the certified classes.

“For far too long, patients and their families have been stretched to the breaking point, both financially and emotionally, as they battle with insurers for the mental health coverage promised by their health plans,” said Meiram Bendat of Psych-Appeal, Inc. and co-counsel for the plaintiffs who uncovered the guideline flaws. “Now a court has ruled that denying coverage based on defective medical necessity criteria is illegal.”

In its decision, the court also held that UBH misled regulators about its guidelines being consistent with the American Society of Addiction Medicine (ASAM) criteria, which insurers must use in Connecticut, Illinois and Rhode Island. Additionally, the court found that UBH failed to apply Texas-mandated substance use criteria for at least a portion of the class period.

The legal opinion is here.

Suicide rates at a record high, yet insurers still deny care

Patrick Kennedy and Jim Ramstad
thehill.com
Originally posted February 15, 2019

Here is an excerpt:

A recent report from the Centers for Disease Control and Prevention (CDC) reinforces the seriousness of our nation’s mental health crisis. Life expectancy is declining in a way we haven’t seen since World War. With more than 70,000 drug overdose deaths in 2017 and suicides increasing by 33 percent since 1999, the message is clear: People are not getting the care they need. And for many, it’s a simple matter of access.

When the Mental Health Parity and Addiction Equity Act, also known as the Federal Parity Law, passed in 2008, those of us who drafted and championed the bill knew that talking about mental health wasn’t enough — we needed to ensure access to care as well. Hence, the Federal Parity Law requires most insurers to cover illnesses of the brain, such as depression or addiction, no more restrictively than illnesses of the body, such as diabetes or cancer. We hoped it would remove the barriers that families like Sylvia’s often face when trying to get help.

It has been 10 years since the law passed and, unfortunately, too many Americans are still being denied coverage for mental health and addiction treatment. The reason? A lack of enforcement.

As things stand, the responsibility to challenge inadequate systems of care and illegal denials falls on patients, who are typically unaware of the law or are in the middle of a personal crisis. This isn’t right. Or sustainable. The responsibility for mental health equity should lie with insurers, not with patients or their providers. Insurers should be held accountable for parity before plans are sold.

The info is here.

Health Insurers Are Still Skimping On Mental Health Coverage

Jenny Gold
Kaiser Health News/NPR
Originally published November 30, 2017

It has been nearly a decade since Congress passed the Mental Health Parity And Addiction Equity Act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, amid an opioid epidemic and a spike in the suicide rate, patients are still struggling to get access to treatment.

That is the conclusion of a national study published Thursday by Milliman, a risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

Among the findings:

• In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.


• Insurers paid primary care providers 20 percent more for the same types of care than they paid addiction and mental health care specialists, including psychiatrists.


• State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington, D.C., it was 63 percent.

The researchers at Milliman examined two large national databases containing medical claim records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and D.C. from 2013 to 2015.

The article is here.

Selling Bad Therapy to Trauma Victims

Jonathan Shedler
Psychology Today
Originally published November 19, 2017

Here is the conclusion:

First, do no harm

Many health insurance companies discriminate against psychotherapy. Congress has passed laws mandating mental health “parity” (equal coverage for medical and mental health conditions) but health insurers circumvent them. This has led to class action lawsuits against health insurance companies, but discrimination continues.

One way that health insurers circumvent parity laws is by shunting patients to the briefest and cheapest therapies — just the kind of therapies recommended by the APA’s treatment guidelines. Another way is by making therapy so impersonal and dehumanizing that patients drop out. Health insurers do not publicly say the treatment decisions are driven by economic self-interest. They say the treatments are scientifically proven — and point to treatment guidelines like those just issued by the APA.

It’s bad enough that most Americans don’t have adequate mental health coverage, without also being gaslighted and told that inadequate therapy is the best therapy.

The APA’s ethics code begins, “Psychologists strive to benefit those with whom they work and take care to do no harm.” APA has an honorable history of fighting for patients’ access to good care and against health insurance company abuses.

Blinded by RCT ideology, APA inadvertently handed a trump card to the worst apples in the health insurance industry.

The article is here.

We live in a culture of mental health haves and have nots

Naomi Freundlich
KevinMD.com
Originally published July 4, 2016

Here is an excerpt:

Let’s start with enforcement. Multiple agencies oversee compliance with the parity laws, including state insurance boards, Medicaid, HHS or the Department of Labor, depending on how and where an individual is insured. Figuring out who to contact when there’s been a violation of parity laws can be difficult, especially when people are experiencing mental health problems.

Furthermore, although obvious discrepancies between behavioral and medical coverage are not all that common, according to Kaiser Health News, many insurers have figured out how to limit mental health costs through more subtle strategies that are harder to track. These include frequent and rigorous utilization review and so-called “fail first” therapies that require providers to try the least expensive therapies first even if they might not be the most effective. The KHN authors note, “Among the more murky areas is ‘medical necessity’ review — in which insurers decide whether a patient requires a certain treatment and at what frequency.”

A survey conducted by the National Alliance on Mental Illness found that patients were twice as likely to be denied mental health care (29 percent) based on “medical necessity” review than other medical care (14 percent).

The article is here.

Mental health care 'is ruining lives'

By Nick Triggle
Health correspondent - BBC
Originally posted February 15, 2016

Inadequate and underfunded mental health care in England is leading to thousands of "tragic and unnecessary deaths" a review has found.

The report - by a taskforce set up by NHS England - said around three-quarters of people with mental health problems received no help at all.

It said more needs to be done to tackle rising suicide rates.

Ministers agreed with the findings, committing a £1bn extra a year by 2020 to treat a million more people.

This is to come out of the £8.4bn the government has promised to the health service during this Parliament and comes on top of extra money already announced for children's services.

Prime Minister David Cameron said the plan would help put "mental and physical healthcare on an equal footing".

The article is here.

Editorial Note: In spite of federal legislation in the United States insuring mental health parity, there are frequent reports of insurance companies not following the law.  Additionally, the mental health system in the US is chronically underfunded through insurance companies as well as local, state, and federal systems.

Common Violations

Parity Track
A website dedicated to inform about mental health parity.

Here are some of the most common ways your parity rights could be violated. Please keep in mind that not every possible parity violation is on this page.

1. I have a separate deductible for behavioral health services that is not part of my overall deductible.

2. My co-pay for behavioral health services is higher than it is for other health services.

3. I have limits on how many time I can see a behavioral health provider.

The website is here.

Is mental health 'parity' law fulfilling its promise?

By Jenny Gold
Kaiser Health News/CNN
Originally posted on September 20, 2015

Here is an excerpt:

The so-called parity law, which was intended to equalize coverage of mental and other medical conditions, has gone a long way toward eliminating obvious discrepancies in insurance coverage. Research shows, for instance, that most insurers have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

But many insurers have continued to limit treatment through other strategies that are harder to track, according to researchers, attorneys and other critics. Among the more murky areas is "medical necessity" review -- in which insurers decide whether a patient requires a certain treatment and at what frequency.

Kamins is among a small group of people around the country to file lawsuits alleging federal or state parity laws were violated when patients with mental illness were held to a stricter "medical necessity" standard than those with other medical conditions.

The entire article is here.

Physicians and Euthanasia: What about Psychiatric Illness, Dementia and Weltschmerz?

By Eva Bolt
BMJ Blogs
Originally posted on February 18, 2015

Here is an excerpt:

Concluding, while most Dutch physicians can conceive of granting requests for euthanasia from patients suffering from cancer or other severe physical diseases, this is not the case in patients suffering from psychiatric disease, dementia or being tired of living. This distinction is partly related to the criteria for due care. For instance, some physicians describe that it is impossible to determine the presence of unbearable suffering in a patient with advanced dementia. Other explanations for the distinction are not related to the criteria for due care. For instance, it is understandable that physicians do not agree with performing euthanasia in a patient with advanced dementia who does not fully understand what is happening, even if the patient has a clear advanced euthanasia directive.

The entire article is here.

The article in the Journal of Medical Ethics is here.

Mental health coverage unequal in many Obamacare plans

By Laura Ungar and Jayne O'Donnell
USA Today
Originally posted March 9, 2015

Insurance coverage for mental and physical illness remains unequal despite promises that Obamacare would help level the playing field, mental health advocates and researchers say.

A new study by the Johns Hopkins Bloomberg School of Public Health found that consumer information on a quarter of the Obamacare plans that researchers examined appeared to go against a federal "parity" law designed to stop discrimination in coverage for people with mental health or addiction problems.

This makes it nearly impossible for consumers to find the best plan to cover their mental health needs, the research suggests.

The entire article is here.

Is My Work “Medically Necessary”?

How insurance companies try to get around rules for mental health care.

By Darcy Lockman
Slate
Originally published January 12, 2015

Here is an excerpt:

I’ve been in private practice since 2010. Most of the people I see submit their bills to their insurance companies for reimbursement. It’s a testament to the integrity in the industry that these reimbursements often come through without a hitch. (Though only in this era of predictable corporate malfeasance could a company simply making good on its contractual obligations be praised for its integrity.) Somehow, four entire years went by during which I never once had to submit to a utilization review. But in the past year, possibly because of increased cost concerns in the wake of the Affordable Care Act, I’ve received a handful of phone calls, each caller requesting that I schedule a talk with a case manager.

The entire article is here.

Kaiser's 2,600 mental health workers strike in California

By Olga R. Rodriguez
AP via Yahoo News
Originally published January 13, 2014

Kaiser Permanente mental health professionals throughout California went on a strike Monday to protest what they say is a lack of staffing that affects care.

The health care provider's 2,600 psychologists, therapists and social workers began the weeklong walkout to demand that Kaiser Permanente offer timely, quality mental health care at its psychiatry departments and clinics, said Jim Clifford, a union member and San Diego psychiatric therapist.

Clifford said some patients have to wait up to two months for follow-up appointments, which prolongs the recovery process.

The entire article is here.

Getting mental health services can be hard, despite law requiring parity

By Lisa Gillespie
The Washington Post
Originally published January 5, 2015

Even though more Americans than before have access to health insurance because of the Affordable Care Act, getting mental health services can still be challenging.

A report released in November concludes that despite a 2008 mental health parity law, some state exchange health plans may have a way to go to even the playing field between mental and physical benefits. The report, released by the advocacy group Mental Health America, was paid for by Takeda Pharmaceuticals U.S.A. and Lundbeck U.S.A., a pharmaceutical company that specializes in neurology and psychiatric treatments.

The report listed the states with the lowest prevalence of mental illness and the highest rates of access to care as Massachusetts, Vermont, Maine, North Dakota and Delaware. Those with the highest prevalence of mental illness and most limited access are Arizona, Mississippi, Nevada, Washington and Louisiana.

The entire article is here.

Denied

When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others

By Scott Pelley
CBS - 60 Minutes
Originally aired on December 14, 2014

Here is an excerpt:

Two years ago tonight, we were reeling from the shock of the murders of 20 first graders and six educators at Sandy Hook Elementary School. Since then, we've learned that the killer suffered profound mental illness. His parents sought treatment but, at least once, their health insurance provider denied payment.

Because of recurring tragedies and an epidemic of suicides, we've been investigating the battles that parents fight for psychiatric care. We found that the vast majority of claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die.



The entire story is here.

Kaiser to pay $4 million fine over access to mental health services

By Cynthia H. Craft
Sacramento Bee
Originally posted September 10, 2014

Health care giant Kaiser Permanente has agreed to pay a $4 million fine to California’s overseer of managed health care following an 18-month battle with state officials over whether Kaiser blocked patients from timely access to mental health services.

(cut)

Moreover, the department found that Kaiser was likely violating state and federal mental health parity laws. The California Mental Health Parity Act requires managed care providers to provide psychiatric services that are equal in quality and access to their primary care services.

The entire article is here.

Expansion of Mental Health Care Hits Obstacles

By Abby Goodnough
The New York Times
Originally published August 28, 2014

Here is an excerpt:

The new law is a big opportunity for mental health providers to reach more people of all income levels. But in Kentucky and the 25 other states that chose to expand Medicaid, the biggest expansion of mental health care has been for poor people who may have never had such treatment before.

Still, private providers face considerable headaches in taking on Medicaid patients, beyond the long-term deterrent of low reimbursement. Ms. Wright, for instance, is still waiting to be approved by some of the managed care companies that provide benefits to Medicaid recipients. Eager to build her client base, Ms. Wright has taken on a handful of new Medicaid enrollees for free while she waits for those companies to approve her paperwork.

“It’s been months and months,” she said. “It’s always there in my mind: Am I going to make it?”

The entire article is here.