Hance Rapid in Grand Canyon National Park, in Arizona. Photo: Kristen M. Caldon/NPS
A new federal court ruling could push employers to take a new look at their health plans' behavioral health coverage exclusions.
U.S. District Judge Ted Stewart suggested in a memorandum decision released Tuesday that an employer health plan might have violated the federal Mental Health Parity and Addiction Equity Act by listing an exclusion for "wilderness treatment programs" in the residential treatment facility coverage description in the behavioral health section but not in the medical/surgical section.
The plaintiffs in the case, Marc S. J. et al. v. Aetna Life Insurance Company, the MITRE Corp. and the Aetna Flex Care PPO Plan, filed a lawsuit in the U.S. District Court for the District of Utah in 2024. The plaintiffs hope to require the plan, which was administered by subsidiaries of CVS Health's Aetna unit, to pay $77,000 for a minor patient's participation in the blueFire Wilderness Therapy outdoor treatment program in Gooding, Idaho.
The MHPAEA requires an employer health plan that covers mental health care or addiction treatment to provide behavioral health coverage provisions that are comparable to the coverage provisions for medical/surgical care.
Aetna Life and the other defendants filed a motion to dismiss the case.
The fact that the plan put a wilderness treatment exclusion in the behavioral health section but not the medical/surgical section shows that "it is plausible that the plan sets different standards for behavioral treatment than it does for its surgical/medical analogy," Stewart wrote in the memorandum.
He let that part of the plaintiffs' case continue.
But the judge dismissed the plaintiffs' request for blueFire program coverage, saying the plan covers behavioral health services provided by a "person who is authorized by law to provide health care services," not the services of a program.
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MITRE, the employer that provided the patient's coverage, is a nonprofit organization that runs research programs and develops technology for the U.S. government, big companies and other clients.
The MITRE plan that covered the patient who used the blueFire program is governed by the Employee Retirement Income Security Act.
Attorneys for MITRE declined to comment on the wilderness treatment coverage ruling.
Karra Porter, president of Christensen & Jensen, the firm that represents the plaintiffs, said the firm is handling about 100 cases across the country that involve similar issues.
"We are finding that most courts recognize these kinds of exclusions as targeting mental health and substance use disorder treatment," Porter said. "It's a pretty transparent violation of the Parity Act."
CVS Health said it's committed to supporting behavioral health communities.
"While this case is still in its early stages and does not represent a final ruling, we remain focused on promoting equitable, high-quality behavioral health care," the company said.
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