California recently passed a law expanding the requirements of
existing behavioral health parity statutes to require that plans reimburse all
"medically necessary" behavioral health treatment, including
substance use disorder treatment, starting in 2021.
Plans will be required to base their decisions about medical
necessity on evidence-based standards developed by nonprofit professional
associations like the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). Previously, plans were only
required to provide coverage at parity for nine behavioral health disorders.
The DSM-5, considered to be the gold standard of psychiatric
diagnostic criteria, contains hundreds of mental health disorders — which means
that California plans will need to drastically expand their coding for
behavioral health treatment.
California payers opposed the legislation. Charles Bacchi, the
CEO of the California Association of Health Plans, wrote in an editorial in the
San Francisco Chronicle that "the bill writes into California law a narrow
definition of medical necessity that will disrupt the ability of physicians and
therapists to determine what is clinically appropriate for their
patients."
However, providers have said the opposite problem exists — that
insurers have turned down medically necessary care due to the payers' internal
standards. California behavioral health care providers and patients have found
reimbursement rules arbitrary, and acute services have not been reimbursed at
proper levels, according to a September 2020 study prepared by Georgetown
University Professor JoAnn Volk for the California Health Care Foundation.
A managed care policy expert who spoke to AIS Health on
background says that insurers opposed the legislation out of concern that they
would have to pay for indefinite care of chronic behavioral health conditions.
The expert pointed out that there's limited data on the efficacy of long-term
treatment for behavioral health conditions, and as a result, plans will struggle
to implement the kind of quality and efficacy metrics for behavioral health
providers that are standard practice in network design for physical care.
Volk agrees that the literature on chronic behavioral health
care is still emerging, but she points out that plans cover a wide variety of
chronic physical conditions.
"There are chronic care issues here, and issuers may say
that it seems like a really open-ended treatment plan," says Volk.
"But that's what they do with diabetes and other lifelong illnesses. In
that regard, it's not different."
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