DANNY P.; ANGELA P.; NICOLE B. v. CATHOLIC HEALTH INITIATIVES; CATHOLIC HEALTH INITIATIVES MEDICAL PLAN-BLUE CROSS BLUE SHIELD
No. 16-35609
UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT
June 6, 2018
D.C. No. 3:15-cv-05024-RBL
Appeal from the United States District Court for the Western District of Washington Ronald B. Leighton, District Judge, Presiding
Submitted April 10, 2018*
San Francisco, California
Filed June 6, 2018
Before: Sidney R. Thomas, Chief Judge, Ferdinand F. Fernandez, Circuit Judge, and David A. Ezra,** District Judge.
Opinion by Judge Fernandez
Parity Act
The panel reversed the district court‘s grant of summary judgment in favor of the defеndant in an action challenging an ERISA plan‘s denial of a claim for the cost of an inpatient stay at a residential mental health treatment facility.
The panel held that the Paul Wellstone and Pete Domenici Mental Health Parity аnd Addiction Equity Act required that the plan‘s coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. Thus, the Parity Act precluded the plan from deciding that it would рrovide room and board reimbursement at licensed skilled nursing facilities for medical and surgical patients, but not at residential treatment facilities for mental health patients. The panel remanded the case to the district court.
COUNSEL
Briаn S. King, Brian S. King P.C., Salt Lake City, Utah; John Walker Wood, The Wood Law Firm PLLC, Seattle, Washington; for Plaintiffs-Appellants.
OPINION
FERNANDEZ, Circuit Judge:
Danny P., Angela P. and Nicоle B. (hereafter collectively “P“) appeal the district court‘s grant of summary judgment to Catholic Health Initiatives (“CHI“) and Catholic Health Initiatives Medical Plan-Blue Cross Blue Shield (collectively “the Plan“). The Plan denied P‘s claim for the cоst of Nicole B.‘s inpatient stay in Island View Residential Treatment Center (“Island View“), a residential mental health treatment facility. We reverse and remand.
BACKGROUND
The Plan is a self-funded group health benefit plan covering CHI employees and their dеpendents. The Plan provides for coverage of “Mental Health Services,” which includes coverage for services related to “the diagnosis and/or treatment of an Illness Affecting Mental Health.” Illnesses affecting mental heаlth are those disorders identified in the current Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.
The Plan covers “[b]ed, board, and general nursing care” as well as “[a]ncillary services” provided at skilled nursing facilities. Skilled nursing facilities are those which are “an institution or distinct part of an institution which is primarily
Nicole B. was covered by the Plan and was admitted to the Island View residential treatment program for the periоd from July 6, 2011, to June 8, 2012. P sought to have the Plan cover the cost of Nicole B.‘s treatment there, including room and board costs. The Plan denied room and board coverage and, after exhausting the Plan‘s administrative remedies, P brought this action under the Employee Retirement Income Security Act (“ERISA“).2 In due course, the parties filed cross-motions for summary judgment and the district court granted summary judgment in favor of the Plan on June 30, 2016. This appeal followed.
JURISDICTION AND STANDARDS OF REVIEW
The district court had jurisdiction pursuant to
We review the district court‘s grant of summary judgment de novo. See Collins v. Gee W. Seattle LLC, 631 F.3d 1001, 1004 (9th Cir. 2011). Summary judgment is only appropriate
DISCUSSION
P asserts that the district court erred when it determined that the Parity Act3 did not require that the Plan‘s coverage for stays at licensed inpatient residential treatment facilities had to be no more restrictive than stays at skilled nursing facilities. We agree.
The Parity Act requires that benefits in a plan that provides for “both [(a)] medical and surgical benefits and [(b)] mental health or substance use disorder benefits,” must not impose more restrictions on the latter than it imposes on the former.
In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that-
(i) the financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the
predominant financial requirements applied to substantially all medical and surgical benefits covered by the plan (or coverage), and there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits; and (ii) the treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.
We note that Congress has conferred upon certain agencies the power to issue rules that give guidance and information regarding the applicatiоn of the Parity Act;7 those agencies have now cooperated in the proposal and issuance of rules.8 In any event, a court will “impose its own construction on the statute . . . in the absence of an
We again note that nothing in the regulations definitively answered the question before us for the period of Nicole B.‘s stay аt the residential treatment facility (2011-2012), but nothing in them was or is contrary to our interpretation. In fact, while the IFRs expressly eschewed fully answering the question,9 they did indicate that mental and medical/surgical benefits must be congruent, and that limiting the former while not placing a similar limitation on the latter would be improper. As the IFRs declared: “Under these regulations, if a plan provides any benefits for a mental health condition or substance use disorder, benefits must be provided for that cоndition or disorder in each classification for which any medical/surgical benefits are provided.” IFRs at 5413. They further declared:
If a plan provides benefits for a mental health condition or substance use disorder in one or more classifications but excludes benefits for that condition or disorder in a classification (such as outpatient, in-network) in which it provides medical/surgical benefits, the
exclusion of benefits in that classification for a mental health condition or substance use disorder otherwise covered under the plan is a treatment limitation. It is a limit, at a minimum, on the type of setting or context in which treatment is offered.
Moreover, the Final Rules explicitly state that coverage at residential treatment facilities must, indeed, be like the coverage at skilled nursing facilities. Final Rules at 68,246-47. Specifically:
Although the interim final regulations did not define the scope of the six classifications of benefits, they directed that plans and issuers assign mental heаlth and substance use disorder benefits and medical/surgical benefits to these classifications in a consistent manner. This general rule also applies to intermediate services provided under the plan or coverage. Plans аnd issuers must assign covered intermediate mental health and substance use disorder benefits to the existing six benefit classifications in the same way that they assign comparable intermediate medical/surgical benefits to these classificаtions. For example, if a plan or issuer classifies care in skilled nursing facilities or rehabilitation hospitals as
inpatient benefits, then the plan or issuer must likewise treat any covered care in residential treatment facilities for mental health or substance user disorders as an inpatient benefit.
CONCLUSION
The district court erred when it decided that during the period from July 6, 2011, to June 8, 2012, the Plan was not required to provide room and board coverage for stays at residential treatment facilities, although it did provide roоm and board at skilled nursing facilities. Were it otherwise, the lack of equity that the Parity Act was designed to repress would have become renascent. Therefore, we reverse the district court‘s judgment and remand for proceedings cоnsistent with this opinion.
REVERSED and REMANDED.