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1 1 (December 21, 2022)

handle is hein.crs/govejwf0001 and id is 1 raw text is: \Congressional R .fesearch Service Behavioral Health Benefit Coverage and Wit v. United Behavioral Health December 21, 2022 The National Institute of Mental Health estimates that nearly 53 million American adults live with a mental illness, and about 24 million (46.2%) received treatment in 2020. The demand for behavioral health services, including mental health and substance use disorder (SUD) treatment, also increased during the COVID-19 pandemic. As a result, access to and coverage for behavioral health services has been a priority for many in the 117th Congress. This Legal Sidebar discusses the U.S. Court of Appeals for the Ninth Circuit's decision in Wit v. United Behavioral Health, which could have implications for individuals with private health insurance plans who are seeking behavioral health coverage. Some stakeholders anticipate that the case's disposition could affect private insurance patients' access to mental health and SUD treatment nationwide. Background Wit was brought as a class action in the U.S. District Court for the Northern District of California against United Behavioral Health (UBH), one of the largest behavioral health plan administrators in the country. At issue in the case is whether UBH may use internal guidelines, which are not based on generally accepted standards of care (GASC), to guide its behavioral health care coverage determinations (i.e., its decisions as to whether the plan's covered benefits are medically necessary, and coverable, for the given enrollees that sought the treatments). According to plaintiffs and the amici curiae, it has become common practice for plan administrators to base coverage decisions, at least in part, on internally developed guidelines as UBH did in Wit. Although plan administrators owe fiduciary duties to their enrollees, federal law does not require private health insurers (or benefit administrators such as UBH) to base their benefit coverage decisions on GASC. Federal law does not define GASC, and there is no universal clinical definition. Instead, the district court in Wit looked at a variety of sources to determine the GASC, including the American Society of Addiction Medicine (ASAM) Criteria, which the court found are the most widely accepted articulation of the Congressional Research Service https://crsreports.congress.gov LSB10881 CRS Legal Sidebar Prepared for Members and Committees of Congress

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