Danny P. v. Catholic Health Initiatives
891 F.3d 1155
9th Cir.2018Background
- The Plan is a self-funded CHI employee health plan that covers “Mental Health Services,” including care at licensed Residential Treatment Facilities and at skilled nursing facilities, and covers room and board at skilled nursing facilities.
- Nicole B., a Plan participant, stayed at Island View Residential Treatment Center from July 6, 2011 to June 8, 2012 for inpatient mental health treatment.
- The Plan denied reimbursement for Nicole’s room and board at the residential treatment facility; after administrative exhaustion, P sued under ERISA seeking coverage for those costs.
- The district court granted summary judgment for the Plan; P appealed to the Ninth Circuit.
- The Ninth Circuit considered whether the Mental Health Parity and Addiction Equity Act (Parity Act) required parity between coverage of inpatient residential treatment facilities for mental health and skilled nursing facilities for medical/surgical care.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the Parity Act requires room-and-board parity between residential mental-health facilities and skilled nursing facilities | Parity Act forbids more restrictive treatment limitations for mental-health benefits; Plan may not cover room and board at residential treatment while covering it at skilled nursing facilities | Parity Act ambiguous as to scope; Plan argues it need not equalize those settings and raises due-process challenge for retroactive application before Final Rules | Reversed: Parity Act requires equivalent treatment limitations; denying room and board at residential treatment while providing it at skilled nursing facilities violated the Act; no due-process bar to applying statutory parity pre-Final Rules |
Key Cases Cited
- Harlick v. Blue Shield of Cal., 686 F.3d 699 (9th Cir. 2012) (rejects notion that inpatient mental-health treatment is appropriately equated to skilled nursing care)
- Chevron U.S.A., Inc. v. Natural Resources Defense Council, Inc., 467 U.S. 837 (1984) (courts defer to reasonable agency interpretations of ambiguous statutes)
- Collins v. Gee W. Seattle LLC, 631 F.3d 1001 (9th Cir. 2011) (standard of review for ERISA summary judgment and statutory interpretation)
- Williams v. Taylor, 529 U.S. 420 (2000) (principles on statutory interpretation and resolving ambiguity)
- Rivers v. Roadway Express, Inc., 511 U.S. 298 (1994) (statutory vagueness does not automatically invalidate pre-guidance application)