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Mental Health Parity Really Does Mean Equal Benefits

Danny P. v. Catholic Health Initiatives, 891 F.3d 1155 (9th Cir. 2018), the Ninth Circuit clarified the full extent of the “parity” required in federal mental health parity law1 which has been in place since 2008.

The Case

In Danny P., the Ninth Circuit held that a particular group health plan (the Catholic Health Initiatives Medical Plan—Blue Cross Blue Shield) was prohibited from denying the same or equivalent room and board coverage in behavioral health facilities that it provided in non-behavioral health facilities, overturning the district court’s decision in favor of the plan.  Specifically, the Court held the plan could not be permitted to deny inpatient room board and costs at a behavioral health inpatient residential treatment facility while simultaneously allowing coverage for non-behavioral health (medical and surgical) inpatient room and board costs at a skilled nursing facility.

The plan at issue was a self-funded group health benefit plan covering Catholic Health Initiatives employees and their dependents, and provided for coverage of “mental health services,” bed, board In, and general nursing care, ancillary services provided at skilled nursing facilities, and also provided coverage for residential treatment facilities (licensed facilities that deal with illnesses affecting mental health). The health insurance plan here was trying to limit payments for behavioral health residential services. Many plans attempt to limit residential behavioral health services because they are much more costly than the physical medicine corollary (e.g. a skilled nursing facility).

As stated in the opinion:

The Parity Act requires that benefits in a plan that provides for “both [ (a) ] medical and surgical benefits and [ (b) ] mental health or substance use disorder benefits,” must not impose more restrictions on the latter than it imposes on the former. 29 U.S.C. § 1185a(a)(3)(A). Specifically, the Parity Act states the following:

In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that—

(i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and

(ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits. 

Id.

See Danny P., 891 F.3d at 1157–58.

The Ninth Circuit explained that neither the Parity Act nor the regulations specifically address every situation, leaving room for interpretation but reasoned the regulations “did indicate that mental and medical/surgical benefits must be congruent, and that limiting the former while not placing a similar limitation on the latter would be improper.”  Id. at 1159.

As the opinion’s mandate ripples outward from the Ninth Circuit and impacts other enforcement actions, the next area of advocacy for parity will likely focus on qualitative or nonquantitative treatment limitations, which will be harder to identify but equally if not more important to the successful and comprehensive treatment of mental health and substance use disorders envisioned by the Parity Act.


1Most health plans must include behavioral health benefits as the Patient Protection and Affordable Care Act mandates.  As such, under the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), plans containing behavioral health benefits must offer them on par with medical/surgical benefits. For more information, see https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-prote....

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About this Author

Erica Morris, Dickinson Wright, Healthcare lawyer
Associate

Erica Morris is an associate attorney at Dickinson Wright in Phoenix, AZ. Her practice areas include healthcare, behavioral healthcare, appellate, and general litigation law. Prior to joining Dickinson Wright, she graduated cum laude from the James E. Rogers College of Law at the University of Arizona, and served as a Judicial Law Clerk to the Honorable Robert M. Brutinel of the Arizona Supreme Court.

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Gregory Moore, Dickinson Wright, Troy, Health Care Law Attorney
Member

Greg Moore co-chairs Dickinson Wright's Behavioral Health Care Practice Group along with his partner Russell A. Kolsrud. Mr. Moore has been a practicing health care attorney since 1991. During his entire career, he has focused on representing and counseling providers of all types and sizes across all existing and developing segments of the industry. He has been recognized as a thought leader and innovator when it comes to the integration of behavioral and physical health care. With 25 years of experience serving clients in the industry, his practice covers the full spectrum of regulatory, transactional, and litigation services.

In January 2009, Greg along with his partner Russ Kolsrud created a Behavioral Health Care Law focused Practice Group in response to the Mental Health Parity and Addiction Equity Act of 2008 and the resulting expanded services clients in the Mental Health and Substance Use Disorder space would need. It was the first of its kind in a national law firm. With more than 50 years of combined experience, Greg and Russ continue to guide their behavioral health care clients through the highly nuanced Patient Protection and Affordable Care Act while maintaining a robust practice across all segments of the healthcare industry.

Throughout his career, Greg has focused on a practice that spans regulatory, transactional and litigation services for healthcare providers and investors in the healthcare industry. Like clients who secure their futures by diversification of their healthcare services, holdings or investments, Greg has diversified his knowledge base across many segments of the healthcare industry in an effort to react to market conditions, regulatory influence and payor policies and focus.

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Russell A. Kolsrud, Dickinson Wright Law Firm, Phoenix, Healthcare and Litigation Law Attorney
Member

Russ Kolsrud is a Member at Dickinson Wright PLLC and is a senior trial lawyer for clients having commercial disputes, health care controversies, transaction disagreements and disputes with government regulatory and licensing agencies. Since 1982, 80% of his practice involved representing clients in the health care industry.

Russ served in the Arizona Attorney General's Office as a trial lawyer for seven years representing the State of Arizona in water, boundary, and regulatory litigation. He appeared before the United States Supreme Court on two occasions. Russ...

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