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Guidelines for Mental Health and Medical/Surgical Claims Need Not Be Identical

by | Sep 21, 2023 |

The U S District Court for the District of Utah has ruled, in L.D. v. United HealthCare, that a group health plan does not violate the Mental Health Parity and Addiction Equity Act (“MHPAEA”) if it uses separate, but comparable, guidelines to determine mental health/substance abuse claims and medical/surgical claims.

Law. MHPAEA requires that the financial requirements and treatment limitations 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 all medical/surgical benefits in a classification. (The six classifications of benefits are: (1) inpatient, in-network; (2) inpatient, out-of-network; (3) outpatient, in-network; (4) outpatient, out-of-network; (5) emergency care; and (6) prescription drugs.) Treatment limitations may be quantitative treatment limitations (i.e., numerical limits) or nonquantitative treatment limitations (such as preauthorization requirements).

Facts. Under the plan’s provisions, “[H]ealth care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, Mental Illness, substance-related and addictive disorders, condition, disease or its symptoms” are covered. The plan must use “Generally Accepted Standards of Medical Practice” to determine if a particular service is covered as “medically necessary.” To make its determination of whether a particular service met these criteria, the plan used one set of guidelines for MH/SUD benefits and another set of guidelines for medical/surgical benefits.

A plan participant’s dependent received residential treatment for a mental health disorder.  When the plan denied benefits for certain parts of this treatment, the participant sued, claiming, among other things, that the plan had violated the MHPAEA by using separate guidelines to determine MH/SUD claims and medical/surgical claims.

District Court.  The court noted that, under the MHPAEA, “any processes, strategies, evidentiary standards, or other factors used in applying the nonquantitative treatment limitation to mental health or substance use disorder benefits in the classification [must be] comparable to, and… applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the limitation with respect to medical/surgical benefits in the classification.” It explained that this meant the guidelines for each type of benefit do not need to be identical, just comparable.

The court then observed that, despite the fact that the plan used separate criteria, it nevertheless defined “medically necessary” in the same way for both mental health and medical/surgical treatment. Next, it stated that, the guidelines the plan used for applying the medical necessity limitation to mental health treatment and medical/surgical treatment were developed using similar processes.

Based on the foregoing, the court determined that the plan’s two sets of guidelines were comparable, because the processes for developing and application of the mental health guidelines “are comparable to and applied no more stringently than for medical/surgical benefits.” Therefore, the court concluded that there was insufficient evidence to show a violation of the MHPAEA and dismissed the participant’s claim.