The U. S. Court of Appeals for the Seventh Circuit, in Hensen v. Group Health Plan Cooperative of South Central Wisconsin, has ruled that the Mental Health Parity and Addiction Equity Act (“MHPAEA”) is not violated when coverage of a single type of mental health treatment differs from the coverage treatment for one type of medical/surgical benefit.
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 benefits cannot be more restrictive than the predominant financial requirements and treatment limitations that apply to substantially all medical/surgical benefits in a classification. (The six classifications of benefits defined in final rules implementing the requirements of the MHPAEA 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.)
Facts. The plaintiffs’ child was diagnosed with autism. They asked their insurer to cover a type of speech therapy as a treatment for the autism. The insurer refused, citing medical evidence that indicated this type of therapy was not effective for a child of this age. The plaintiffs sued, claiming that the insurer had violated the MHPAEA by applying its requirement that treatments be “evidence-based” more stringently to mental health benefits for autism than it did to one medical benefit, chiropractic care, where age was not used as a criterion for effective treatment. However, the lower court ruled in favor of the insurer and dismissed the claim. The plaintiffs appealed the lower court’s adverse determination to the Seventh Circuit.
Appeals Court. The Seventh Circuit began its analysis by stating that the MHPAEA “permits health insurers, when determining what treatments to cover, to rely on the available medical literature. They must make sense of this literature as they find it, no matter how thin or developing it may be. The way in which the medical literature considers the efficacy of and makes recommendations regarding various treatments will vary for any number of reasons—from the availability of study participants across demographics, to funding considerations, to judgments regarding study design, to which patient characteristics researchers expect to bear on treatments’ efficacy. Such variance affects the results—and treatment recommendations—of medical study. It’s unsurprising that literature on autism focuses more on efficacy by age than does literature on chiropractic care.” Therefore, the court found that by examining and applying appropriate medical literature standards, the insurer had met its obligations with respect to the determination of the plaintiffs’ claim.
The court also ruled that the plaintiffs’ argument fails for a more fundamental reason. The plaintiffs had attempted to “make their case” by identifying a single medical benefit that was handled differently from the mental health benefits they sought. However, the relevant statutory provision requires that treatment limitations applicable to mental health benefits be no more restrictive than treatment limitations “applied to substantially all medical and surgical benefits covered by the plan… Plaintiffs proceed as if they can prevail by showing that their insurer approached coverage for one mental health benefit more restrictively than coverage for one medical benefit. They are mistaken.”
The court went on to note that, “a showing that an insurer limits a mental health benefit more than it does one medical benefit cannot show that it so limits substantially all such benefits.”
Based on the foregoing rationale, the Seventh Circuit ruled in favor of the insurer by affirming the lower court’s decision to dismiss the plaintiffs’ claim.