In March 2019, a landmark federal court decision – Wit v. United Behavioral Health (UBH) – demonstrated how insurers are able to mitigate their responsibilities under state and federal parity laws through the use of flawed medical necessity criteria to deny coverage of mental health and substance use disorder care on the grounds that care is not “medically necessary”. The court determined that UBH’s internally developed criteria for making medical necessity determinations were inconsistent with generally accepted standards of behavioral healthcare and were inappropriately influenced by a financial incentive to suppress costs. In November 2020, the court ordered UBH to reprocess 67,000 claims and mandated that UBH use guidelines published by nonprofit clinical societies when making medical necessity determinations.
Ending the use of flawed medical necessity criteria is critical because insurers use these criteria to deny patients needed mental health and substance use disorder care. In order to realize the promise of parity, Illinois must require that health insurers cover medically necessary mental health and substance use disorder care and that they follow generally accepted standards of behavioral healthcare when making medical necessity decisions. By putting these clear standards and requirements in place, Illinois can remove barriers to mental health and substance use disorder care at a time of rapidly escalating need.
- SB697/HB2595 – Fact Sheet
- Standards of Care for Behavioral Health Services (National Council for Behavioral Health)
- Game Changer: Implications of the Wit v. United Behavioral Health Ruling Webinar (Video)
- 10 Steps to Securing Insurance Coverage for Mental Health Care (September 11, 2019)
- Wit v. UBH – Landmark Decision: UnitedHealthcare Used Defective Criteria to Reject Coverage for Mental Health and Addiction Treatment Services, Federal Court Finds (March 5, 2019)