California’s parity law requires insurers to reimburse patients for medically necessary residential treatment, a California appeals court has ruled. The decision reverses a lower court ruling.
On June 10, the California Court of Appeal for the Second Appellate District, in the case Rea v. Blue Shield of California, said that the health plan is required by the 1999 California Mental Health Parity Act (MPHA) to cover medically necessary residential treatment for the eating disorders anorexia nervosa and bulimia, even though treatment for these illnesses is not listed specifically as one of the required treatments in the language of the 1999 law.
Leaders of the California Psychiatric Association (CPA) explained that the ruling means that the listing of treatments in the 1999 law is not exhaustive but illustrative and that the intent of the legislation is to provide coverage for mental illness that is comparable to that for other medical illness, even if the treatments are not identical.
In its ruling the appeals court stated, “We do not interpret the concept of ‘parity’ to require treatments for mental illnesses to be identical to those mandated for physical illnesses; rather, given the principle that treatments for the two types of illnesses are in many cases not comparable, parity instead requires treatment of mental illnesses sufficient to reach the same quality of care afforded physical illnesses.”
“Parity means parity,” stressed Ronald Thurston, M.D., immediate past president of the CPA and a member of the CPA’s Government Affairs Committee. “The health plan and the association of health plans argued that the California law didn’t say it had to cover residential treatment. We argued that the treatments described in the law were not exhaustive but were representative of what it means to have true parity.
“It’s up to state organizations to ensure that the nuts and bolts of parity get implemented,” Thurston told Psychiatric News. “It’s one thing to have parity on paper, but if you don’t prove it in the courts and enforce it through the regulatory agencies, it won’t happen.”
Crucial to success in the case was the participation of Helen Thomson, a former member of the California legislature who was one of the original authors of the California parity law. (She is also the wife of APA member and former APA Assembly Recorder Captane Thomson, M.D.) Thomson and the CPA jointly filed an amicus brief arguing that the original intent of the parity law was to be inclusive, not exhaustive.
In that brief, the CPA also drew on the decision in a 2011 case tried in federal court because it involved a self-insured federal ERISA plan that revolved around the same question: whether the state parity law required coverage of residential treatment for an eating disorder. In that case, Harlick v. Blue Shield of California, the court ruled against Blue Shield and said coverage was required.
“Harlick holds that within the financial limitations of a health plan’s coverage, the MHPA requires a health plan to provide medically necessary treatment for a severe mental illness, even if that treatment is not identified as a health plan benefit and is not one of the four benefits [outpatient services, inpatient hospital services, partial hospital services, and prescription drugs] identified in” the state’s health and safety code, CPA and Thomson wrote in their brief.
Citing APA treatment guidelines, they also noted that “residential treatment, the treatment benefit in dispute in the present matter, is medically accepted as necessary in certain circumstances for the effective treatment of eating disorders. . . .”
Melinda Young, M.D., APA’s Area 6 (California) Trustee, immediate past speaker of the Assembly, and CPA government affairs federal legislative representative, said the CPA has been actively involved in legislative and judicial processes in California on issues that involve parity and appropriate psychiatric care and treatment. She said the CPA benefited from a grant from APA’s Committee on Advocacy and Litigation Fund.
“California is blessed in being a big state; we have five district branches that are very active in local issues on the ground while CPA, as the umbrella organization, can focus on legislative and judicial advocacy statewide,” she said. “This is one of several examples of how alert members and district branches can identify significant legislative, regulatory, and judicial issues and make significant changes in their states.” ■