Litigation Provides Clues to Ongoing Challenges in Implementing Insurance Parity

• Published in: Journal of health politics, policy and law Vol. 42; no. 6; pp. 1065 - 1098
• Main Authors: Berry, Kelsey N., Huskamp, Haiden A., Goldman, Howard H., Rutkow, Lainie, Barry, Colleen L.
• Format: Journal Article
• Language: English
• Published: United States Duke University Press 01.12.2017; Duke University Press, NC & IL
• Subjects: Ambiguity; Applied behavior analysis; Autism; Autism Spectrum Disorder - therapy; Certification; Compliance; Disorders; Drug abuse; Enforcement; Health care industry; Health insurance; Humans; Insurance; Insurance coverage; Insurance Coverage - legislation & jurisprudence; Insurance Coverage - standards; Insurance, Health - legislation & jurisprudence; Insurance, Health - standards; Law; Laws; Legislatures; Licensure - standards; Litigation; Medical treatment; Medicine; Medicine and Health; Mental disorders; Mental health; Mental health services; Mental Health Services - legislation & jurisprudence; Mental Health Services - standards; Parity; Political Science; Politics; Private medical care; Private Sector; Public Health and Health Policy; Public Policy; Public Sector; Substance abuse; Substance use; Substance use disorder; Substance-Related Disorders - therapy; United States; Violations; United States > US; Mental Health Parity and Addiction Equity Act; insurance parity; health reform; mental health and substance use disorders; public health litigation
• ISSN: 0361-6878; 1527-1927
• DOI: 10.1215/03616878-4193630

Over the past twenty-five years, thirty-seven states and the US Congress have passed mental health and substance use disorder (MH/SUD) parity laws to secure nondiscriminatory insurance coverage for MH/SUD services in the private health insurance market and through certain public insurance programs. However, in the intervening years, litigation has been brought by numerous parties alleging violations of insurance parity. We examine the critical issues underlying these legal challenges as a framework for understanding the areas in which parity enforcement is lacking, as well as ongoing areas of ambiguity in the interpretation of these laws. We identified all private litigation involving federal and state parity laws and extracted themes from a final sample of thirty-seven lawsuits. The primary substantive topics at issue include the scope of services guaranteed by parity laws, coverage of certain habilitative therapies such as applied behavioral analysis for autism spectrum disorders, credentialing standards for MH/SUD providers, determinations regarding the medical necessity of MH/SUD services, and the application of nonquantitative treatment limitations under the 2008 federal parity law. Ongoing efforts to achieve nondiscriminatory insurance coverage for MH/SUDs should attend to the major issues subject to private legal action as important areas for facilitating and monitoring insurer compliance.