226 Cal. App. 4th 1209
Cal. Ct. App.2014Background
- Plaintiffs Marissa Rea and Kelly Melachouris have eating disorders and are Blue Shield plan enrollees seeking residential treatment coverage.
- The California Mental Health Parity Act (Parity Act) requires coverage for the diagnosis and medically necessary treatment of severe mental illnesses on the same terms as other medical conditions.
- Harlick v. Blue Shield of California held that residential treatment for anorexia nervosa is required under the Parity Act when medically necessary.
- The trial court sustained a demurrer, holding the Parity Act is bounded by the Knox–Keene Act’s basic health services and that the Act’s language is limited to a finite list.
- The court reverses, adopting a broad reading of Parity Act coverage for medically necessary mental health treatment rather than a strict Knox–Keene “basic services” approach.
- The court emphasizes parity as equal access to medically necessary mental health care, not identical treatment to physical illnesses.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does the Parity Act require residential treatment for eating disorders when not listed as basic health services? | Rea/ Melachouris: yes, Parity Act mandates all medically necessary treatment for severe mental illness. | Blue Shield: no, parity governs basic Knox–Keene services; not all medically necessary care. | Yes; residential treatment must be covered to achieve parity. |
| What does the phrase 'shall include' in the Parity Act's implementing regulation mean in relation to Knox–Keene? | Regulation supports broader coverage beyond basic services. | Regulation aligns with limiting to basic Knox–Keene services. | Broader interpretation controls; not limited to basic services. |
| Is DMHC’s position controlling on whether residential treatment must be covered? | Regulatory interpretation supports coverage. | DMHC position should control. | No; court independently interprets statute, not bound by agency position. |
| Does the Parity Act read to limit mental-health coverage to a finite set of treatments? | No, 'medically necessary treatment' is not exhausted by enumerated items. | Yes, per Knox–Keene structure and regulation. | No; Parity Act requires coverage of medically necessary treatments to reach parity. |
Key Cases Cited
- Harlick v. Blue Shield of California, 686 F.3d 699 (9th Cir. 2012) (held Parity Act requires coverage for medically necessary residential treatment of eating disorders)
- Consumer Watchdog v. California Department of Managed Health Care, 225 Cal.App.4th 862 (Cal. App. 4th 2014) (discussed autism behavioral treatment under parity; informs limits of parity scope)
- In re Marriage of Angoco & San Nicolas, 27 Cal.App.4th 1527 (Cal. App. 1994) (doctrinally supports treatment of statutory terms as enlargement, not limitation)