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Court Says Group Health Plan May Not Exclude Specified Autism Treatments

On Behalf of | Mar 23, 2021 |

The District Court for the Northern District of California has ruled, in Doe v. United Behavioral Health, that the exclusion of certain specified procedures related to the treatment of autism violates the Mental Health Parity and Addiction Equity Act (“MHPAEA”).

Facts. A group health plan participant’s son was diagnosed with autism and treated with Applied Behavioral Analysis (ABA) and Intensive Behavioral Therapies (IBT).

Although the plan covered autism and Autism Spectrum Disorder, it contained exclusions for ABA and IBT. The plan’s claims administrator denied coverage for these treatments, citing the plan’s exclusions, and in response the participant sued under the MHPAEA

Law.  The MHPAEA requires that the financial requirements (e.g., coinsurance and copays) and treatment limitations (e.g., visit limits) imposed on mental health or substance use disorder (“MH/SUD”) benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits in a classification. 

With regard to any non-quantitative treatment limitation (“NQTL”), the MHPAEA final regulations provide that a group health plan or health insurance issuer may not impose a NQTL with respect to MH/SUD benefits in any classification unless, under the terms of the plan (or health insurance coverage) as written and in operation, any processes, strategies, evidentiary standards, or other factors used in applying the NQTL to MH/SUD benefits in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used in applying the limitation to medical/surgical benefits in the same classification.

District Court. The claims administrator asserted that, under the MHPAEA’s provisions, “[n]othing… shall be construed… as requiring a group health plan (or health insurance coverage offered in connection with such a plan) to provide any mental health or substance use disorder benefits.” Therefore, it argued that the plan is not required to provide specific mental health benefits relating to autism.

The court noted that under the MHPAEA, the treatment limitations applicable to MH/SUD benefits must be no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan and there can be no separate treatment limitations that are applicable only with respect to MH/SUD benefits. It then ruled that “In this case, the ABA and IBT exclusions only apply to mental health disorders.  Therefore, the exclusions create a separate treatment limitation applicable only to services for a mental health condition.  By doing so, the exclusion violates the plain terms of the MHPAEA.”

The court also ruled that the plan contravenes the MHPAEA by requiring “more restrictive limitations than the predominant treatment limitations applied to substantially all medical and surgical benefits. The exclusion carves out and rejects from coverage a core treatment for autism.”

Therefore, the court ruled in favor of the participant and ordered the plan’s claims administrator to cover the ABA and IBT treatments.