Litigation Provides Clues to Ongoing Challenges in Implementing Insurance Parity
Litigation Provides Clues to Ongoing Challenges in Implementing Insurance Parity
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DOI：
10.1215/03616878-4193630
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发表时间：
2017-12-01
影响因子：
4.2
通讯作者：
Barry, Colleen L.
中科院分区：
文献类型：
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作者：
Berry, Kelsey N.;Huskamp, Haiden A.;Barry, Colleen L.
在过去的25年里，37个州和美国国会通过了精神健康和物质使用障碍（MH/SUD）平等法，以确保私人健康保险市场和某些公共保险计划对MH/SUD服务的非歧视性保险覆盖。然而，在此期间，许多当事人提起诉讼，指控违反保险平价。我们研究了这些法律挑战背后的关键问题，作为理解平等执行缺乏的领域的框架，以及这些法律解释中正在进行的模糊领域。我们确定了所有涉及联邦和州平等法的私人诉讼，并从37起诉讼的最终样本中提取了主题。存在争议的主要实质性议题包括平价法保障的服务范围、某些康复疗法（如自闭症谱系障碍的应用行为分析）的覆盖范围、MH/SUD提供者的资格认证标准、关于MH/SUD服务的医疗必要性的确定，以及2008年联邦平价法规定的非定量治疗限制的适用。正在进行的为MH/ sud提供非歧视性保险的努力应关注私人法律行动所涉及的主要问题，作为促进和监测保险公司遵守规定的重要领域。
Over the past twenty-five years, thirty-seven states and the US Congress have passed mental health and substance use disorder ( MH/SUD) parity laws to secure nondiscriminatory insurance coverage for MH/SUD services in the private health insurance market and through certain public insurance programs. However, in the intervening years, litigation has been brought by numerous parties alleging violations of insurance parity. We examine the critical issues underlying these legal challenges as a framework for understanding the areas in which parity enforcement is lacking, as well as ongoing areas of ambiguity in the interpretation of these laws. We identified all private litigation involving federal and state parity laws and extracted themes from a final sample of thirty-seven lawsuits. The primary substantive topics at issue include the scope of services guaranteed by parity laws, coverage of certain habilitative therapies such as applied behavioral analysis for autism spectrum disorders, credentialing standards for MH/SUD providers, determinations regarding the medical necessity of MH/SUD services, and the application of nonquantitative treatment limitations under the 2008 federal parity law. Ongoing efforts to achieve nondiscriminatory insurance coverage for MH/SUDs should attend to the major issues subject to private legal action as important areas for facilitating and monitoring insurer compliance.