Initiatives
National Advocacy
Together with other member organizations, we craft policy statements, weigh in on legislation, educate Congress and other governmental bodies, and develop relationships on Capital Hill.
Constituent Advocacy — We’re all constituents! How can we best advocate with our elected officials?
Advocacy Toolkit -- PsiAN created this toolkit, with input from experienced advocates, former lobbyists and individuals who have run political campaigns. Be sure to attend one of our webinars to learn about the Toolkit and being the best advocate you can for therapies of depth, insight and relationship.
Telehealth
With COVID-19 and therapy sessions going online, PsiAN developed a position statement on telementalhealth -- what needs to be included, considered and covered, so that therapies of depth, insight and relationship can be safely provided.
Standards of Care and Medical Necessity — Wit v. UBH
This landmark class action lawsuit is a significant victory for patients and quality mental healthcare, and paves the way for parity and quality mental healthcare in the US. PsiAN is committed to educating policymakers and the public about the issues in this case, and advocating for key legislation to ensure that everyone is entitled to receive the care they need. The remedies applied against UBH were stiff: UBH needs to reprocess 67,000 claims, use only medical necessity criteria developed by non-profit clinical speciality associations, and train its staff in applying medical necessity criteria.
Mental Health Parity
The Mental Health Parity and Addiction Equity Act of 2008 ushered in the first sweeping national legal mandate for parity for mental health treatment benefits. The 2010 Affordable Care and Patient Protection Act strengthened parity, by naming mental health care, including psychotherapy, as an Essential Health Benefit. Unfortunately, many insurers are still not fully in compliance with the law, and insurers commit many violations—through practices around prior authorization for services, inadequate provider networks, and unfair reimbursement, among others.
To move towards real parity, new legislation incorporates key aspects of the Wit v UBH ruling, and adds new requirements for insurers. These news state laws usher in an era of accountability for commercial health insurers and set the stage for national reform.
California, Fall 2020
expands parity protections to all conditions described in the DSM, rather than to just nine previously identified mental health disorders
establishes a state-wide definition of “medical necessity,” and requires insurers to make benefit determinations that are consistent with “generally accepted standards of care” from the landmark Wit decision
requires insurers to exclusively apply medical necessity criteria developed by non-profit clinical specialty associations
expressly forbids insurers from limiting benefits or coverage for mental health and substance use disorders to short-term or acute treatment
Illinois, Summer 2021
Incorporates key components of the California bill, including medical necessity criteria and mandate to use non-profit criteria and guidelines
Also, requires insurance companies to maintain an adequate network of mental health care providers and provide their beneficiaries with timely and convenient access to mental health treatment
People will not have to wait more than 10 business days to see a provider after requesting an initial appointment or 20 business days after requesting a repeat or follow-up appointment
In the Chicago area, people will not have to travel more than 30 miles or 30 minutes from their home to see a provider. In other areas of Illinois, the limit expands to 60 miles or 60 minutes
Requires insurers to cover out-of-network copays, if no in-network providers are available within those time and distance limits
Oregon, Summer 2021
Oregon became the third state to successfully pass medical necessity criteria legislation
requires that managed care organizations use non-profit clinical specialty association criteria and guidelines when determining the type of care covered for patients
Background on Wit v UBH
This class action suit was brought on behalf of patients who had United Behavioral Health (UBH) insurance policies, but were denied coverage or payment by UBH for residential treatment, substance use disorder, and outpatient mental health treatment.
Care that was recommended by patients’ doctors was denied by United. Many of these patients suffered unnecessarily, and some even died.
In February of 2019, Chief Magistrate Judge Joseph Spero of the United States District Court for the Northern District of California released his sharp and detailed rebuke of United Behavioral Health for putting profits before people from 2011-2017 across four states: Connecticut, Illinois, Rhode Island and Texas. UBH was found liable for breach of fiduciary duty and liable for the plaintiffs’ denial of benefits claim.
The Court looked to standards of care as defined by professional organizations including the American Society of Addiction Medicine (ASAM), Level of Care Utilization System (LOCUS) and Child and Adolescent LOCUS (CALOCUS).
In ruling on the case against UBH, the Court noted that UBH created its own guidelines to determine whether it would cover treatment, and that these internal guidelines failed to meet “generally accepted standards of care.” The guidelines were designed to enhance UBH’s profits, and they were heavily influenced and ultimately controlled by its finance department -- not its clinical team. Coverage was mainly for controlling acute symptoms or crises, while coverage for more chronic or underlying issues was denied.
Judge Spero determined that UBH violated its fiduciary duty by utilizing criteria that were inconsistent with generally accepted standards of care and also violated a number of state laws that require the use of the ASAM criteria for substance abuse disorders.
Judge Spero also outlined the Standards of Generally Accepted Care, and these are the Standards that PsiAN is working on integrating into legislation.
Standards of Care, per the Wit v UBH ruling
•Treat the underlying condition, not only current symptoms
•Treat co-occurring conditions
•Treat at the least intensive level of care that is safe and effective
•Err on the side of caution
•Effective treatment includes services to maintain function
•Determine duration of treatment based on individual
•Address unique needs of children / adolescents
•Make level-of-care decisions based on a multidimensional assessment