Millions of people in the U.S. need mental health and substance use disorder services, collectively known as behavioral health, but do not get them. Despite the high numbers of people who need behavioral health care, people often have trouble accessing the care they need. Last week, NHeLP along with 27 other behavioral health advocacy groups filed an amicus brief in support of a class of people with insurance administered by United Behavioral Health in Wit v. United Behavioral Health. The amicus brief asks the 9th Circuit Court of Appeals to affirm theCancel district court’s decision that found problems with United Behavioral Health (UBH) using medical necessity criteria for services that were not consistent with generally-accepted standards of care. The district court found that UBH illegally used its medical necessity criteria to deny behavioral health care that was promised to the class, and it ordered UBH to reprocess claims for the class, among other remedies. This decision reflected the importance of insurers providing the medically necessary behavioral health care promised by an individual’s insurance plan, not merely the care UBH agreed was willing to provide.
For decades, Congress has tried to remediate insurance practices that limit access to behavioral health care. This began with the Mental Health Parity Act and its expansion under the Mental Health Parity and Addiction Equity Act, continued with Congress requiring behavioral health as an essential health benefit for ACA plans, and has further expanded when Congress enacted more recent requirements in the 21st Century Cures Act and the Consolidated Appropriation Act of 2020. But with each new bridge built to cover the gaps to ensure fair and equitable access to these important services, insurers dig new—and often illegal—trenches to find ways to deny people behavioral health care they need, even when that care is expressly covered by their insurance plans.
In Wit v. UBH, the District Court found that UBH promised behavioral health services and then used utilization management standards that were not consistent with generally-accepted standards of care to hollow out that promise and illegally deny needed, covered care. After a 10-day trial, the District Court found that the UBH had violated its fiduciary duties under ERISA by using internal guidelines inconsistent with the terms of the class members’ health insurance plans and that it did so deliberately to protect its financial bottom line. Even UBH’s expert at trial testified that no physician “worth their salt” would use UBH’s guidelines to make clinical judgments because of irreconcilable differences between the guidelines and the generally accepted standards of care required by the plans’ own terms.
NHeLP et al’s amicus brief supports the 67,000 class members by providing the Court with additional information about the serious need for behavioral health services in this country, and the importance of affirming the District Court’s holdings to ensure that people receive the behavioral health services their insurers promised to provide. Behavioral health needs are great in the United States and for many they are unmet; even UBH’s affiliated health insurance plan, UnitedHealth Group, reports that only 42% of U.S. residents receive the behavioral health care they need. The impact of not receiving such care, especially when insurers focus largely on acute rather than chronic behavioral health care, is grave, leading to preventable crisis care, institutionalization, and worse. Not only do insurance practices to deny behavioral health care lead to worse patient outcomes, they also shift costs to families, employers, and governments.
In particular, practices like those of UBH to deny care using internal medical necessity guidelines can be confusing and a significant barrier to care. Even though there may be appeal processes available to fight denials of care, it is incredibly difficult and potentially costly for an individual to show their care is necessary when the guidelines used to approve the care are inconsistent with generally accepted standards of care. People also find it difficult to appeal denials of needed care when in the midst of the very mental health crisis necessitating that care. To file litigation to challenge the use of internal guidelines can be even more prohibitive given the need for costly experts. Thus, the District Court’s class certification in Wit aggregates the economic power of the insureds and without it, UBH might face no meaningful consequence for systemic misbehavior. For those reasons, NHeLP and 27 other groups asked the 9th Circuit to affirm the District Court’s decisions in Wit.
Partnership to End Addiction
Public Justice Center
Link to brief: