When it comes to the issue of mental health care and substance use treatment, it’s imperative that states properly negotiate mental health and addiction parity protections into contracts with managed care organizations (MCOs) administering Medicaid plans. This includes empowering providers to challenge denials of medically necessary care.

To help promote timely and appropriate care for Medicaid recipients, the National Council for Behavioral Health has released an article outlining suggested contractual language that state Medicaid directors should consider when they negotiate managed care contracts. The primer is co-authored by Psych-Appeal’s Meiram Bendat.

“The potential confusion regarding the Mental Health Parity and Addiction Equity Act compliance requirements for Managed Care Organizations (‘MCOs’) in the Medicaid sector, as well as the often complicated medical necessity determination and appeal procedures may jeopardize an individual’s ability to obtain medically necessary care,” write the authors. “It is imperative that states negotiating Medicaid contracts with MCOs make use of new safeguards and mental health and addiction parity protections to ensure access to essential services for vulnerable populations. This includes empowering providers to effectively challenge adverse benefit determinations impacting their patients’ access to medically necessary care.”

In “Protecting Consumer Access to Mental Health and Addiction Care in Managed Medicaid Plans,” Bendat and the National Council for Behavioral Health outline eight points of discussion, along with proposed contract terms, that are focused on the appeals process and plan disclosure requirements:

1. Communications,
2. Standing,
3. Access to plan documents,
4. Access to clinical criteria,
5. Network access,
6. Negotiated coverage modifications,
7. Access to claims data, and
8. Denials implicating mental health and addiction parity.

These recommendations serve as a useful guide in clarifying the rights, expectations and responsibilities of all parties, including states, MCOs, patients and providers.

Psych-Appeal and the National Council for Behavioral Health have also compiled tips on how providers can negotiate contracts with MCOs.

 

NOTE: “Protecting Consumer Access to Mental Health and Addiction Care in Managed Medicaid Plans” is for educational purposes only. The incorporation of any of these recommendations into managed care contracts should be decided upon after consultation with qualified legal counsel.

In a significant mental health ruling, the United States District Court for the Northern District of California has certified Wit v UBH as a class action. With this decision, the federal court has come one step closer to ordering health insurance giant United Behavioral Health (“UBH”) to revamp its medical necessity criteria and reprocess thousands of outpatient, intensive outpatient and residential treatment claims it denied since 2011.

Plaintiffs in two companion class-action lawsuits, Wit et al. v. UnitedHealthcare et al. and Alexander et al. v. United Behavioral Health (referred to collectively as “Wit v UBH”) allege that UBH systematically denies coverage for mental health treatment by developing and applying “medical necessity” criteria that are far more stringent than generally accepted standards of care.

“This class certification order is an important victory in the fight for mental health parity,” said Psych-Appeal’s Meiram Bendat, co-counsel for the plaintiffs. “It signals that health insurers can be held responsible, on a class-wide basis, for denying insurance coverage for mental health treatment to those desperately in need. Without class certification, few, if any, patients will have the financial or emotional resources necessary to challenge this type of misconduct individually.”

The plaintiffs’ health plans, governed by the Employee Retirement Income Security Act (ERISA), require UBH to evaluate medical necessity according to generally accepted standards of care. UBH’s proprietary medical necessity criteria purport to reflect these standards. However, the plaintiffs allege that a push for profits has led UBH to develop criteria that overemphasize acute mental health and substance use disorder symptoms and disregard chronic or complex conditions that require ongoing care, in contravention of generally accepted standards.

UBH is a subsidiary of UnitedHealth Group and is the country’s largest managed behavioral health care organization, serving more than 60 million members.

In addition to Wit v UBH, Psych-Appeal and Zuckerman Spaeder LLP have been appointed class counsel by the federal court and also represent plaintiffs in similar mental health parity cases against Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Texas, New Mexico, Montana and Oklahoma), Magellan Health Services of California and Blue Shield of California.

Psych-Appeal, Grant & Eisenhofer P.A., and Zuckerman Spaeder LLP have filed a class-action lawsuit against Magellan and Blue Shield of California on behalf of adolescents suffering from mental health and substance use disorders. The suit alleges that the health insurers limit and deny coverage for outpatient and residential treatment using strict guidelines that are created internally by Magellan.

“These guidelines by Magellan and Blue Shield of California are far more restrictive than the standards of care that are generally accepted within the mental health community,” said Meiram Bendat, president of Psych-Appeal. “When insurers develop criteria that distort or disregard generally accepted treatment standards, profitability trumps patient safety.”

The plaintiffs in the case include a father whose teenage son was denied residential treatment for substance abuse and major depression, and a mother whose son was denied intensive outpatient treatment for the same conditions.

The complaint was filed in the U.S. District Court, Northern District of California.

Today’s second annual State of the Union in Mental Health and Addiction called for changing public discourse on mental health as well as establishing a comprehensive “System We Need” to help achieve full implementation of the Parity Act.

“We’re here to set a political agenda, not a medical agenda,” said former Rep. Patrick Kennedy, founder of The Kennedy Forum, during his State of the Union speech. “I’m proud to be part of that march for progress.”

Kennedy continued, saying that he is involved in efforts to have a presence at the upcoming Democratic and Republican national conventions, and will petition for changes in party platforms.

Kennedy also outlined the behavioral health “System We Need” to improve on mental health care and ensure integrated delivery of that care.

“We cannot build the system we need unless we break the silence,” said Kennedy.

The second annual State of the Union in Mental Health and Addiction was hosted by The Kennedy Forum and the Satcher Health Leadership Institute. Follow the conversation on Twitter at #MHSOTU.

Psych-Appeal founder Meiram Bendat gave an hour-long seminar today at Yale School of Medicine. His presentation, titled “Addressing Treatment Incursions by Insurers in the Era of Mental Health Parity,” covered an array of issues applicable to mental health parity, from federal parity rules and regulatory enforcement to the scrutinization of insurer denials.

“We certainly don’t penalize people in the medical context for obesity by denying them care for diabetes down the road,” remarked Bendat during the presentation. “So why should we do anything different in this capacity?”

When reviewing an insurer’s denial of mental health treatment, Bendat urged attendees to compare the insurer’s criteria with generally accepted criteria, including state-mandated criteria as well as physician specialty association guidelines issued by the American Society of Addiction Medicine (ASAM) and the American Academy of Child and Adolescent Psychiatry (AACAP).

We thank all those who attended and contributed to the thoughtful discourse. The seminar was hosted by Yale School of Medicine’s Department of Psychiatry Grand Rounds.