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Image by Amit Kumar from Pixabay
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Policy Memo: Medical Necessity Standards for Mental Health Parity in California
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Navita Kalair (1), Clio Korn (2), Larissa J Maier (3), Thomas Pospiech (4,5), Neiloy R Sircar (6), Trisha Vaidyanathan (7)
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Keywords: mental health; health care; medical necessity; mental health parity; California
Executive Summary: One in six adults in California experience a mental illness, but up to 63% may not receive mental health services (California Health Care Foundation 2018). The treatment gap is even larger for people with substance use disorders (SUDs), and lack of treatment can lead to increased rates of suicide, homelessness, and incarceration (Weiner 2019a). Mental health parity laws require health insurance companies to cover mental and physical health services equally. These laws have helped reduce individual costs for mental health and SUD treatment (Ettner et al. 2016), but recent reports emphasize that California has not yet achieved full parity (Davenport, Gray, and Melek 2019; Parity Track 2019a; Weiner 2019b). Insurers commonly circumvent parity laws when denying behavioral health claims due to lack of “medical necessity,” a determination created by the insurer that lacks sufficient government oversight. We identify three issues with definitions of medical necessity and propose policy solutions that will 1) align medical necessity criteria with current scientific and medical standards, 2) regulate the influence of financial self-interest in assessing medical necessity, and 3) improve transparency of medical necessity criteria to clients. These solutions will help increase access to equitable, client-centered behavioral health care in California.
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References
- California Health Care Foundation. 2018. “Mental health in California: For too many, care not there.” March. https://www.chcf.org/wp-content/uploads/2018/03/MentalHealthCalifornia2018.pdf
- Dangor, Graison. 2019. “'Mental health parity' is still an elusive goal in U.S. insurance coverage.” NPR. June 7. https://www.npr.org/sections/health-shots/2019/06/07/730404539/mental-health-parity-is-still-an-elusive-goal-in-u-s-insurance-coverage
- Davenport, Stoddard, Travis J. Gray, and Stephen P. Melek. 2019. “Addiction and mental health vs. physical health: widening disparities in network use and provider reimbursement.” Milliman, Nov 20. https://www.milliman.com/en/insight/addiction-and-mental-health-vs-physical-health-widening-disparities-in-network-use-and-p
- Erman, Erica A. and Russell A. Kolsrud. 2019. “Highlights from Wit v. United Behavioral Health.” Dickinson-Wright, March 20. https://www.dickinson-wright.com/news-alerts/highlights-from-wit-united-behavioral-health-case
- Ettner, Susan L., Jessica M. Harwood, Amber Thalmayer, Michael K. Ong, Haiyong Xu, Michael J. Bresolin, Kenneth B. Wells, Chi-Hong Tseng, and Francisca Azocar. 2016. "The Mental Health Parity and Addiction Equity Act evaluation study: Impact on specialty behavioral health utilization and expenditures among “carve-out” enrollees." Journal of Health Economics 50: 131-143. https://doi.org/10.1016/j.jhealeco.2016.09.009
- Health Insurance Authority, Government of Ireland. 2020. “Consumer information: Cancelling your health insurance plan.” April 15. https://www.hia.ie/consumer-information/cancelling-your-health-insurance-plan
- Jarkon, Liat. 2020. “Why insurers should cover mental health care to lower costs.” Fortune. February 5. https://fortune.com/2020/02/05/mental-health-care-coverage-insurance-costs/
- The Kennedy Forum. 2020. “New bills introduced in CA to prioritize mental health and addiction treatment.” January 21. https://www.thekennedyforum.org/blog/new-bills-introduced-in-ca-to-prioritize-mental-health-and-addiction-treatment/
- McGinty, Emma, Bernice Pescosolido, Alene Kennedy Hendricks, and Colleen L. Barry. 2018. “Communication strategies to counter stigma and improve mental illness and substance use disorder policy.” Psychiatric Services 69 (2): 136–46. https://doi.org/10.1176/appi.ps.201700076
- National Alliance on Mental Illness. 2015. “A long road ahead: Achieving true parity in mental health and substance use care.” April. https://www.nami.org/Support-Education/Publications-Reports/Public-Policy-Reports/A-Long-Road-Ahead/2015-ALongRoadAhead
- Office of the Commonwealth Ombudsman, Government of Australia. 2020. “The right to change.” April 15 https://www.ombudsman.gov.au/__data/assets/pdf_file/0020/29423/Right-to-Change-DL-Fyler-Web.pdf
- Office of the Governor of California. 2020. “2020-2021 Governor’s Budget (Proposed).” January 10. http://www.ebudget.ca.gov/budget/2020-21/#/BudgetSummary
- Parity Track. 2019a. “State Report Card: California.” https://pjk-uploads.s3.amazonaws.com/www.paritytrack.org/uploads/2018/09/StateReportCard_05_CA.pdf
- Parity Track. 2019b. “Legislative overview in New Jersey.” https://www.paritytrack.org/report/new-jersey/new-jersey-legislation/
- Parity Track. 2019c. “Statutory overview in Tennessee: Legislation signed into law.” https://www.paritytrack.org/report/tennessee/tennessee-law/
- Rosenbaum, Sara, Brian Kamoie, D. Richard Mauery, and Brian Walitt. 2003. “Medical necessity in private health plans: Implications for behavioral health care. “ Substance Abuse and Mental Health Services Administration and Center for Mental Health Services, Department of Health and Human Services. Pub. No. SMA 03-3790. https://doi.org/10.1037/e415852005-001
- Roy, Anusha. 2019. “A look at Colorado’s 8 new laws related to mental health.” 9news. May 24. https://www.9news.com/article/news/a-look-at-colorados-8-new-laws-related-to-mental health/73-d4da707b-b5f4-41fb-bd99-e11dd5b25185
- Stanford Justice Advocacy Project. 2017. “Confronting California’s continuing prison crisis: The prevalence and severity of mental illness among California prisoners is on the rise.” Stanford University. https://law.stanford.edu/wp-content/uploads/2017/05/Stanford-Report-FINAL.pdf
- Weiner, Jocelyn. 2019a. “Breakdown: California’s mental health system, explained.” CalMatters, April 30. https://calmatters.org/explainers/breakdown-californias-mental-health-system-explained/
- Weiner, Jocelyn. 2019b. “Californians aren’t getting the mental health care they’re legally guaranteed. Why not?” CalMatters, Dec 8. https://calmatters.org/projects/california-mental-health-care-parity/
Navita Kalair is a dentist and a recent graduate in the Dental Public Health Program at the UCSF School of Dentistry. Her interests lie in Health Services Research and she is passionate about provision of preventive dentistry in children, less privileged and special needs population. Her research focused on evaluating a school-based preventive dental health program in a Californian rural county.
Clio Korn is a neuroscientist and science policy enthusiast. She is currently a postdoctoral scholar in the Department of Psychiatry and Behavioral Sciences at UCSF. She studies how the brain allows us to flexibly adapt to changing circumstances and what goes wrong when this ability is impaired, with the aim of guiding development of targeted therapies for the cognitive symptoms of psychiatric disorders. Clio is a member of the Leadership Team of the Science Policy Group at UCSF.
Larissa J. Maier is passionate about drug policy, mental health, and human rights. She is an advocate for universal health care and committed to ending the systemic oppression of Black people and other minority groups in the U.S. and beyond. She is a postdoctoral scholar at the UCSF Department of Clinical Pharmacy investigating how local variation in cannabis and opioid policies impact health outcomes. Larissa is a member of the Leadership Team of the Science Policy Group at UCSF. She received her PhD from the University of Zurich and worked at the United Nations Office on Drugs and Crime (UNODC) in Vienna.
Thomas Pospiech is a chemical biology PhD student at the University of Michigan completing his dissertation research at UCSF. His research focuses on using cryo-electron microscopy (cryo-EM) to create 3D models of proteins involved in neurodegenerative and heart disease. These models help scientists to understand how these proteins work and to create new therapies. Tom is also a member of the Leadership Team of the Science Policy Group at UCSF and serves as the Treasurer. His interests in science policy are varied and have included advocating for basic science research funding in Washington, D.C., leading advocacy workshops at UCSF’s Annual LGBTQIA+ Health Forum, and co-hosting a pre-screening and bioethics fireside chat of the documentary “Human Nature”.
Neiloy R. Sircar is a human rights lawyer and postdoctoral scholar with the UCSF Center for Tobacco Control Research and Education. His subject-matter expertise includes global and public health, global governance, and health in humanitarian crises. His research focus is in further developing the legal dimensions to global health and in particular human rights-based approaches to health. He is supported by National Cancer Institute Grant CA-113710.
Trisha Vaidyanathan is a neuroscience PhD student at UCSF and a passionate advocate for mental health. She is currently studying how the brain regulates sleep. Her research focuses on how an understudied population of cells in the brain called astrocytes mediates the transition between wake and sleep. The aim of this research is to develop better treatments for a range of sleep disorders, such as insomnia.
Acknowledgments
We thank Amiee Alden, Allie Jones, Ben Rubin, Michael Bedard, and the members of the Science Policy Group at UCSF for their input and support throughout our efforts to learn about and advocate for mental health care parity.
Clio Korn is a neuroscientist and science policy enthusiast. She is currently a postdoctoral scholar in the Department of Psychiatry and Behavioral Sciences at UCSF. She studies how the brain allows us to flexibly adapt to changing circumstances and what goes wrong when this ability is impaired, with the aim of guiding development of targeted therapies for the cognitive symptoms of psychiatric disorders. Clio is a member of the Leadership Team of the Science Policy Group at UCSF.
Larissa J. Maier is passionate about drug policy, mental health, and human rights. She is an advocate for universal health care and committed to ending the systemic oppression of Black people and other minority groups in the U.S. and beyond. She is a postdoctoral scholar at the UCSF Department of Clinical Pharmacy investigating how local variation in cannabis and opioid policies impact health outcomes. Larissa is a member of the Leadership Team of the Science Policy Group at UCSF. She received her PhD from the University of Zurich and worked at the United Nations Office on Drugs and Crime (UNODC) in Vienna.
Thomas Pospiech is a chemical biology PhD student at the University of Michigan completing his dissertation research at UCSF. His research focuses on using cryo-electron microscopy (cryo-EM) to create 3D models of proteins involved in neurodegenerative and heart disease. These models help scientists to understand how these proteins work and to create new therapies. Tom is also a member of the Leadership Team of the Science Policy Group at UCSF and serves as the Treasurer. His interests in science policy are varied and have included advocating for basic science research funding in Washington, D.C., leading advocacy workshops at UCSF’s Annual LGBTQIA+ Health Forum, and co-hosting a pre-screening and bioethics fireside chat of the documentary “Human Nature”.
Neiloy R. Sircar is a human rights lawyer and postdoctoral scholar with the UCSF Center for Tobacco Control Research and Education. His subject-matter expertise includes global and public health, global governance, and health in humanitarian crises. His research focus is in further developing the legal dimensions to global health and in particular human rights-based approaches to health. He is supported by National Cancer Institute Grant CA-113710.
Trisha Vaidyanathan is a neuroscience PhD student at UCSF and a passionate advocate for mental health. She is currently studying how the brain regulates sleep. Her research focuses on how an understudied population of cells in the brain called astrocytes mediates the transition between wake and sleep. The aim of this research is to develop better treatments for a range of sleep disorders, such as insomnia.
Acknowledgments
We thank Amiee Alden, Allie Jones, Ben Rubin, Michael Bedard, and the members of the Science Policy Group at UCSF for their input and support throughout our efforts to learn about and advocate for mental health care parity.
DISCLAIMER: The findings and conclusions published herein are solely attributed to the author and not necessarily endorsed or adopted by the Journal of Science Policy and Governance. Articles are distributed in compliance with copyright and trademark agreements.
ISSN 2372-2193
ISSN 2372-2193