The Importance of Generally Accepted Standards of Care

In most health insurance policies, autism spectrum disorder (ASD) falls under the benefits category of mental health, not physical medicine. This categorization is related to ASD’s inclusion in the Diagnostic Statistical Manual (DSM-V) which is the handbook used by health care professionals in the U.S. and much of the world as the authoritative guide to the diagnosis of mental disorders. In addition to a diagnosis of ASD, many autistics, including children, have other mental health conditions such as anxiety, attention disorders, or depression. They may also experience physical symptoms such as sleep disorders, gastrointestinal problems, seizures, etc. The article below explains an important legal case about mental health insurance benefits and how its reversal could harm the autism community.

Background

There are often differences between how insurance companies cover mental health conditions and how they cover physical medicine conditions. Unlike patients who use insurance benefits for a physical condition—one that is medical or surgical in nature—patients with mental health conditions often face provider visit limits, annual dollar caps, and tougher medical necessity standards.

The Case

In 2019 there was a landmark case for our community, Wit v. United Behavioral Health. In this federal case, 11 plaintiffs sued United Behavioral Health (UBH), a subsidiary of United Healthcare, in a class action (large group) lawsuit. The plaintiffs claimed that UBH failed its beneficiaries by going against the generally accepted standard of care for mental health conditions. The term “generally accepted standards of care” means standards that are widely accepted as medically necessary by medical professionals who treat such patients. During the trial, the plaintiffs presented evidence that UBH used its own guidelines—instead of generally accepted standards of care—to keep costs down.

The Court’s Decision

At the end of the trial, the District Court found UBH had violated several laws. In the ruling, the court set out 8 principles that insurance companies must use when making medical necessity determinations for mental health conditions:

1. Underlying conditions, not just symptoms, must be treated.
2. Co-occurring conditions must be considered when deciding on the appropriate level of care.
3. Treatment should be at the least intensive and least restrictive level that is safe and effective.
4. When the appropriate level of care is not clear, the provider should place the patient in a higher level of care.
5. Services needed to maintain progress or prevent regression are part of an effective treatment plan.
6. The right length of treatment is based on the individual needs of the patient; there is no set duration for treatment.
7. The needs of children and teens must be taken into account when making level-of-care decisions.
8. The appropriate level of care should be based on a holistic multidimensional assessment.

These principles could be applied to employer-sponsored insurance plans (those governed by federal “ERISA” law) as persuasive authority. Four states have recognized the importance of these these principles and passed them as state law (California, Illinois, Oregon, and Georgia).

How the Court’s Decision Supports the Needs of the Autism Community

For the autism community, these principles address the following common insurance problems:

• Denials or partial denials for treatment because of a patient’s “lack of progress”
• Denials of intensive treatment because a patient does not have “severe” challenges
• Partial denials for treatment because the patient is making progress or is likely to make progress at a reduced level of care
• Denials or partial denials for treatment due to the number of years the patient has been receiving treatment
• Insufficient consideration of the patient’s developmental stage for medical necessity determinations

The Reversal

In March of 2022, a three-judge panel of the Ninth Circuit Court of Appeals overturned the District Court’s decision and ruled that it is “not unreasonable” for insurers to provide benefits outside of generally accepted standards of care. In response, the plaintiffs are requesting an en banc rehearing which would include eleven Ninth Circuit judges. There is no set timetable for when the decision on rehearing will be issued.

The implications of the reversal—and if the rehearing is denied—for our community are significant. Autistic individuals need coverage for medically necessary services based on recommendations from the medical community that serves them, not based on factors that are important to health insurance companies like cost.

The Future

The Wit decision represents the most successful effort to date to hold health insurers accountable for unequal coverage of mental health disorders. Given the importance of this case, if the District Court’s decision is not upheld, it is likely the plaintiffs would request a review to the U.S. Supreme Court.

Autism Speaks and other groups that advocate for those with mental health disorders are concerned about the Wit reversal and are following the appeal closely. We encourage the autism community to keep up to date with the developments of this case and its impact in their state and across the nation. Autism Speaks will provide additional updates as they become available.