For the last 15 years the federal Mental Health Parity Act (MHPA) of 1996, has required group health carriers to provide total dollar coverage no differently for mental health treatment than for physical health treatment. The State of California enacted its own mental health parity law in 1999 requiring private health insurance plans to provide equal coverage for serious mental illnesses in adults (SMI) and “serious emotional disturbances” (SED) in children. [Assembly Bill 88]. The public policy behind AB88 is to reduce the heavy personal and societal cost of living with untreated mental illness.
AB88 prevents carriers from writing terms into their health plans that provide for higher copayments, deductibles, and limits on number of outpatient or inpatient days covered. Quite simply, the law is that even if a plan has terms setting such limits on mental health coverage, the carrier must pay in parity what it pays for physical treatment coverage.
Despite these federal and state laws being “on the books” for over a decade, the group health insurance industry has been unrelenting in denying equal benefits for eating disorders. I frankly believe a “cost/benefit” analysis by insurance executives has led them to accept the costs of being sued on a case by case basis rather than comply with the law as responsible corporate citizens.
The most recent battle, fought by Blue Shield of California, was lost by the carrier in the case of Harlick v. Blue Shield of California, 2011 DJDAR 13132. The case involved the one adult anorexic, Jeanene Harlick, who suffered from anorexia for over 20 years. Due to severe self starvation, she was at 65% of her healthy weight. She admitted herself to an out of state eating disorder unit, Castlewood Treatment Center, in Missouri. On admission, she had to have a feeding tube inserted.
Jeanene did not obtain pre-authorization from Blue Shield for her out-of-state treatment. Candlewood had no medical doctors or nurses or staff, but relied exclusively on the use of psychologists. Jeanene’s policy did not such a facility because it did not meet the policy’s definition of a covered “skilled nursing facility.”
There was no dispute in the trial and appeal that the definition excluded the type of facility actually used by Jeanine in Missouri. But, the Ninth Circuit ruled, it also was not disputed that Jeanine’s care was “medically necessary.” California’s mental health parity law lists nine examples of “mental illness” covered by the Act: Anorexia Nervosa is one of those. However, many other mental illnesses are also covered by the general wording of the statute.
The Ninth Circuit essentially held that treatment by psychologists for a serious mental illness is to be covered in parity with medical treatment by physicians and nurses providing treatment for physical illness or injury. The Ninth Circuit held specifically that Residential Treatment for Anorexia Nervosa is to be covered in parity with coverage for physical illness.
California has 3.4 million group health policyholders. Eating Disorders affect about 6/10% (.6) of the adult U.S. population, of which about 1/3 receive treatment. The average age of onset is 19, but the condition is growing among teenage girls. See generally: http://www.nimh.nih.gov/statistics/1EAT_ADULT_ANX.shtml
Blue Shield of California (Anthem) has indicated it will appeal to the U.S. Supreme Court. While that is the Company’s legal right, I believe the carrier’s continuing violations of the parity law is unconscionable. Young people will continue suffer, and some of them will die, because of the cold calculating and arrogant attitude of the carrier in fighting compliance case by case.
Useful References:
http://www.dol.gov/ebsa/newsroom/fsmhparity.html
http://www.scribd.com/doc/65850619/Anorexia-Insurance-Coverage
http://www.mathematica-mpr.com/PDFs/snapshot.pdf
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