oversight

Mental Health and Substance Use: Treatment Exclusions in Employers' Health Insurance Coverage

Published by the Government Accountability Office on 2012-05-31.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States Government Accountability Office
Washington, DC 20548



           May 31, 2012

           The Honorable George Miller
           Ranking Member
           Committee on Education and the Workforce
           House of Representatives

           Subject: Mental Health and Substance Use: Treatment Exclusions in Employers’
                    Health Insurance Coverage

           Dear Mr. Miller:

           On November 30, 2011, we issued a report entitled Mental Health and Substance
           Use: Employers’ Insurance Coverage Maintained or Enhanced Since Parity Act, but
           Effect of Coverage on Enrollees Varied. 1 The report was written to fulfill a mandate
           in the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity
           Act of 2008 (MHPAEA) that required us to examine trends in coverage for mental
           health conditions and substance use disorders (MH/SU). 2 As a follow-up to the
           report, you asked us to provide additional information about plans’ treatment
           exclusions for MH/SU. 3

           The information about treatment exclusions for MH/SU was based on survey data
           that we collected for our report to determine the extent to which employers covered
           MH/SU during the plan year in effect at the time of our survey—either 2011 or
           2010—and in 2008. We surveyed a stratified random sample of small, medium,
           large, and very large employers about their most popular health plans for either the
           2011 or 2010 plan year, as well as for 2008. We fielded our web-based survey
           between May 18, 2011, and July 1, 2011, to 707 employers, selected from the
           sampling frame we developed using the Lexis Nexis corporate database. 4 We
           received usable responses from 168 employers, after following up with
           nonrespondents to encourage their participation, for a 24 percent response rate. All
           168 employers offered coverage of mental health conditions, substance use
           1
            See GAO-12-63, Nov. 30, 2011.
           2
            Pub. L. No. 110-343, Div. C, Tit. V, Sub. B, § 512, 122 Stat. 3765, 3892 (Oct. 3, 2008).
           3
            This follow-up information was initially provided to you on December 16, 2011.
           4
            To develop our sampling frame, we used the Dossier function of the Lexis Nexis corporate database to select
           32,431 U.S.-based companies on January 18, 2011. We selected privately held and publicly traded parent
           companies with between 51 to 100,000 employees that were headquartered in the United States. We drew our
           random sample of employers from this sampling frame. We excluded employers from our survey that had 50 or
           fewer employees because MHPAEA did not apply to them.



                                                                                 GAO-12-761R Treatment Exclusions
disorders, or both, in either the 2011 or 2010 plan year, 2008 plan year, or both plan
years. Given our overall response rate of 24 percent, our survey results are not
generalizable. Rather, the survey responses provide information limited to
responding employers’ coverage of MH/SU in the 2011 or 2010 plan year and 2008
plan year. We did not verify the accuracy of the employers’ responses or assess
compliance with MHPAEA.

We conducted our work in December 2011 and April and May 2012 in accordance
with all sections of GAO’s Quality Assurance Framework that are relevant to our
objectives. The framework requires that we plan and perform the engagement to
obtain sufficient and appropriate evidence to meet our stated objectives and to
discuss any limitations in our work. We believe that the information and data
obtained, and the analysis conducted, provide a reasonable basis for any findings
and conclusions.

In summary, table 1 provides the incidence of treatment exclusions for MH/SU for
the 2011 or 2010 plan year and the 2008 plan year for employers that responded to
our survey. In total, for the 2011 or 2010 plan year, of the 96 employers that
responded to our question about whether their most popular plan excluded coverage
for any specific treatments related to MH/SU, 39 employers reported excluding a
treatment. In comparison, for the 2008 plan year, of the 81 employers that
responded to our question about whether their most popular excluded coverage for
any specific treatments related to MH/SU, 27 employers reported excluding a
treatment. The enclosure provides details on the treatment exclusions summarized
in table 1.




2                                                  GAO-12-761R Treatment Exclusions
Table 1: The Incidence of Plan Treatment Exclusions for Mental Health Conditions and Substance Use
Disorders Among Survey Respondents

                                                                                                      Percent of plans that
                                                                                                      excluded a treatment
                                                                                                   (based on number of plans
                                                                      Number of times a           in each year where employer
                                                                   treatment was listed as            indicated a treatment
                                                                        an exclusion                     was excluded)
                                                                                     a        b                   a             b
 Treatment exclusion                                                2011 or 2010          2008        2011 or 2010       2008
 Alcoholism                                                                         2         3               5.1%      11.1%
 Attention deficit disorder                                                         2         0               5.1%       0.0%
 Autism                                                                             4         2              10.3%       7.4%
 Behavioral disorders/problems/
 delays/counseling/health/training/
 services                                                                           12        3              30.8%      11.1%
 Bioenergetic therapy                                                               2         1               5.1%       3.7%
 Biofeedback                                                                        4         2              10.3%       7.4%
 Borderline intellectual functioning                                                5         4              12.8%      14.8%
 Conditions not in the Diagnostic and
 Statistical Manual                                                                 3         5               7.7%      18.5%
 Conduct/impulse disorders                                                          2         3               5.1%      11.1%
 Court-ordered treatments/treatments for
 the incarcerated                                                                   11        9              28.2%      33.3%
 Custodial services                                                                 10        5              25.6%      18.5%
 Developmental disorder/
 disabilities/delays                                                                10        6              25.6%      22.2%
 Developmental reading, arithmetic, and
 language disorders                                                                 5         4              12.8%      14.8%
 Educational testing                                                                2         1               5.1%       3.7%
 Experimental/investigational                                                       3         1               7.7%       3.7%
 Feeding disorders                                                                  2         0               5.1%       0.0%
 Hypnosis                                                                           5         1              12.8%       3.7%
 I.Q. testing                                                                       5         4              12.8%      14.8%
 Learning disabilities                                                              9         5              23.1%      18.5%
 Marital therapy/counseling                                                         4         4              10.3%      14.8%
 Mental retardation                                                                 7         3              18.0%      11.1%
 Organic mental disorders                                                           6         5              15.4%      18.5%
 Primal therapy                                                                     2         1               5.1%       3.7%
 Psychological testing                                                              6         4              15.4%      14.8%
 Residential treatment facility                                                     6         3              15.4%      11.1%
 Rolfing/structural integration                                                     2         1               5.1%       3.7%
 Sex change/transsexual surgery                                                     7         2              18.0%       7.4%
 Sex counseling                                                                     2         2               5.1%       7.4%
 Sexual dysfunction/deviation                                                       9         2              23.1%       7.4%
 Sleep disorders/insomnia                                                           3         3               7.7%      11.1%
 Smoking cessation/tobacco addiction                                                8         2              20.5%       7.4%
 Special education                                                                  4         1              10.3%       3.7%
 V-code                                                                             3         1               7.7%       3.7%
 Vocational/religious (pastoral) counseling                                         12        5              30.8%      18.5%
Source: GAO analysis of employers’ survey responses on health insurance coverage.




3                                                                                        GAO-12-761R Treatment Exclusions
Note: The list of treatment exclusions was determined based on the responses provided to us by employers in our survey for
the employers’ most popular plan in the plan year in effect at the time of our survey (2011 or 2010) and the 2008 plan year.
a
 For the 2011 or 2010 plan year, of the 96 employers that responded to the question about whether their most popular health
plan excluded coverage for any specific treatments related to MH/SU, 39 employers reported excluding a treatment.
b
 For the 2008 plan year, of the 81 employers that responded to the question about whether their most popular health plan
excluded coverage for any specific treatments related to MH/SU, 27 employers reported excluding a treatment.


                                                        –––––

The report will be available at no charge on our website at http://www.gao.gov.

If you or your staff have any questions about this information, please contact me at
(202) 512-7114 or dickenj@gao.gov. Jennifer Grover, Assistant Director, and
Elizabeth Conklin also made key contributions to this product. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the last page
of this report.

Sincerely yours,




John E. Dicken
Director, Health Care
Enclosure




4                                                                         GAO-12-761R Treatment Exclusions
Enclosure

                    Details of Plan Treatment Exclusions for Mental Health
                           Conditions and Substance Use Disorders

This enclosure provides the specific language regarding treatment exclusions for
mental health conditions and substance use disorders for the 2011 or 2010 plan
year and the 2008 plan year for employers who responded to our survey. When
specific language for a treatment exclusion was used by more than one plan, the
enclosure table provides information about the number of plans that used the
language. The enclosure table provides details of the treatment exclusions
summarized in table 1.

Table 2: Details of Plan Treatment Exclusions for Mental Health Conditions and Substance Use
Disorders Among Survey Respondents

                                            Details of responses on treatment exclusions
Treatment exclusion       2011 or 2010 Plan Year             2008 Plan Year
Alcoholism                •   Alcohol and/or Substance Abuse •   Alcohol and/or Substance Abuse
                              treatments are not considered      treatments are not considered mental
                              mental health benefits.            health benefits.
                          •   Alcohol. Services or supplies  •   Services or supplies furnished for
                              furnished for diagnosis or         diagnosis or treatment of alcoholism,
                              treatment of alcoholism,           controlled substance abuse, chemical
                              controlled substance abuse,        dependency, tobacco addiction, or
                              chemical dependency, tobacco       codependency treatment for any of the
                              addiction, or codependency         above except as provided in the
                              treatment for any of the above     Schedule of Benefits.
                              except as provided in the      •   For Acute Care, rehabilitative care, or
                              Schedule of Benefits.              diagnostic testing or evaluation of Mental
                                                                 or Nervous Conditions, Alcoholism,
                                                                 Substance Abuse or Addiction, or for
                                                                 Pain Rehabilitation, except as specified
                                                                 as a Covered Service in this Plan.
Attention deficit         •   Charges for education, learning     •    None
disorder                      disabilities, job training,
                              behavioral problems or attention
                              deficit disorders whether or not
                              provided by a facility that also
                              provides medical or psychiatric
                              treatment.
                          •   For any care that extends
                              beyond traditional medical
                              management for autistic disease
                              of childhood, Pervasive
                              Development Disorders,
                              Attention Deficit Disorder,
                              learning disabilities, behavioral
                              problems, or mental retardation.




5                                                                     GAO-12-761R Treatment Exclusions
Enclosure

                                          Details of responses on treatment exclusions
Treatment exclusion     2011 or 2010 Plan Year                    2008 Plan Year
Autism                  •   Educational therapy or other          •   Autism and Other Pervasive
                            nonmedical ancillary services for         Developmental Disorders (PDD).
                            learning disabilities,                •   Expenses for nonmedical ancillary
                            developmental delays, autism, or          services and treatment related to
                            mental retardation.                       learning disabilities, developmental
                        •   For any care that extends                 delays, autism, or mental retardation.
                            beyond traditional medical
                            management for autistic disease
                            of childhood, Pervasive
                            Development Disorders,
                            Attention Deficit Disorder,
                            learning disabilities, behavioral
                            problems, or mental retardation.
                        •   Expenses for nonmedical
                            ancillary services and treatment
                            related to learning disabilities,
                            developmental delays, autism, or
                            mental retardation.
                        •   Intensive behavioral therapy for
                            treatment of autism spectrum
                            disorders.
Behavioral disorders/   •   Special education, school testing     •   Special education, school testing or
problems/delays/            or evaluations, counseling,               evaluations, counseling, therapy or care
counseling/health/          therapy or care for learning              for learning deficiencies or behavioral
training/services           deficiencies or behavioral                problems.
                            problems.                             •   Service or care related to the educational
                        •   Educational services and                  treatment of behavioral disorders.
                            treatment of behavioral               •   Services and supplies which are
                            disorders, together with services         rendered in connection with mental
                            for remedial education including          illnesses not classified in the
                            evaluation or treatment of                International Classification of Diseases of
                            learning disabilities, minimal            the U.S. Department of Health and
                            brain dysfunction, developmental          Human Services or extended beyond the
                            and learning disorders,                   period necessary for evaluation and
                            behavioral training, and cognitive        diagnosis of learning and behavioral
                            rehabilitation. This includes             disabilities or for mental retardation.
                            services, treatment, or
                            educational testing and training
                            related to behavioral (conduct)
                            problems, learning disabilities, or
                            developmental delays.
                        •   Educational/behavioral services
                            that are focused on primarily
                            building skills and capabilities in
                            communication, social
                            interaction, and learning.
                        •   Behavioral problems and
                            learning disabilities. Charges for
                            education, learning disabilities,
                            job training, behavioral problems,
                            or attention deficit disorders
                            whether or not provided by a
                            facility that also provides medical
                            or psychiatric treatment.




6                                                                 GAO-12-761R Treatment Exclusions
Enclosure

                                              Details of responses on treatment exclusions
Treatment exclusion         2011 or 2010 Plan Year                     2008 Plan Year
Behavioral disorders/       •   Nonmedical counseling or
problems/delays/                ancillary services, including, but
counseling/health/              not limited to, Custodial Services,
training/services (cont.)       education, training, vocational
                                rehabilitation, behavioral training,
                                biofeedback, neurofeedback,
                                hypnosis, sleep therapy,
                                employment counseling, back
                                school, return-to-work services,
                                work hardening programs, driving
                                safety, and services training,
                                educational therapy or other
                                nonmedical ancillary services for
                                learning disabilities,
                                developmental delays, autism, or
                                mental retardation.
                            •   Services and supplies which are
                                rendered in connection with
                                mental illnesses not classified in
                                the International Classification of
                                diseases of the U.S. Department
                                of Health and Human Services;
                                or extended beyond the period
                                necessary for evaluation and
                                diagnosis of learning and
                                behavioral disabilities or for
                                mental retardation. (Two plans
                                used this language.)
                            •   For any care that extends
                                beyond traditional medical
                                management for autistic disease
                                of childhood, Pervasive
                                Development Disorders,
                                Attention Deficit Disorder,
                                learning disabilities, behavioral
                                problems, or mental retardation.
                            •   Behavioral training and services,
                                educational therapy or other
                                nonmedical ancillary services for
                                learning disabilities,
                                developmental delays, or mental
                                retardation are also excluded
                                except as specified in the Severe
                                Mental Illness of a Member of
                                any Age and Serious Emotional
                                Disturbances of a Child section
                                of Section IV.
                            •   Treatment of behavioral
                                disorders.
                            •   Behavioral counseling.
                            •   Treatment for behavioral health
                                conditions.




7                                                                      GAO-12-761R Treatment Exclusions
Enclosure

                                            Details of responses on treatment exclusions
Treatment exclusion       2011 or 2010 Plan Year                     2008 Plan Year
Bioenergetic therapy      •   Therapies that do not meet             •   Therapies that do not meet national
                              national standards for mental              standards for mental health professional
                              health professional practice,              practice, including but not limited to,
                              including but not unlimited to,            Erhard/The Forum, primal therapy,
                              Erhard/The Forum, primal                   rolfing, sensitivity training, bioenergetic
                              therapy, rolfing, sensitivity              therapy, or crystal healing therapy.
                              training, bioenergetic therapy, or
                              crystal healing therapy.
                          •   Treatment modalities that have
                              not been incorporated into the
                              commonly accepted therapeutic
                              repertoire as determined by
                              broad-based professional
                              consensus, such as primal
                              therapy, rolfing or structural
                              integration, bioenergetic therapy,
                              and obesity control therapy.
Biofeedback               •   Nonmedical counseling or               •   Biofeedback. (Two plans used this
                              ancillary services, including but          language.)
                              not limited to, Custodial Services,
                              education, training, vocational
                              rehabilitation, behavioral training,
                              biofeedback, neurofeedback,
                              hypnosis, sleep therapy,
                              employment counseling, back
                              school, return-to-work services,
                              work hardening programs, driving
                              safety, and services training,
                              educational therapy or other
                              nonmedical ancillary services for
                              learning disabilities,
                              developmental delays, autism, or
                              mental retardation.
                          •   Nonmedical counseling or
                              ancillary services including but
                              not limited to, Custodial Services,
                              education, training, vocational
                              rehabilitation, biofeedback,
                              neurofeedback, hypnosis, sleep
                              therapy, employment counseling,
                              back school, return-to-work
                              services, work hardening
                              programs, and driving safety.
                          •   Biofeedback. (Two plans used
                              this language.)
Borderline intellectual   •   Counseling for borderline              •   Counseling for borderline intellectual
functioning                   intellectual functioning. (Five            functioning. (Four plans used this
                              plans used this language.)                 language.)
“Conditions not in the    •   Services performed in connection       •   Services performed in connection with
Diagnostic and                with conditions not classified in          conditions not classified in the current
Statistical Manual”           the current edition of the                 edition of the Diagnostic and Statistical
                              Diagnostic and Statistical Manual          Manual of the American Psychiatric
                              of the American Psychiatric                Association. (Three plans used this
                              Association. (Three plans used             language.)
                              this language.)




8                                                                    GAO-12-761R Treatment Exclusions
Enclosure

                                            Details of responses on treatment exclusions
Treatment exclusion      2011 or 2010 Plan Year                      2008 Plan Year
“Conditions not in the                                               •   Conditions which (the plan) determines
Diagnostic and                                                           to lack a recognizable III-R classification
Statistical Manual”                                                      in the most current edition of the
(cont.)                                                                  Diagnostic and Statistical Manual of
                                                                         Mental Disorders of the American
                                                                         Psychiatric Association.
                                                                     •   Treatment of any condition categorized
                                                                         as an Axis II condition under the then
                                                                         current Diagnostic and Statistical Manual
                                                                         of the American Psychiatric Association
                                                                         without any clinical likelihood of
                                                                         improvement, except for acute
                                                                         exacerbations of the condition.
Conduct/impulse          •   Educational services and                •   Treatment for conduct and impulse
disorders                    treatment of behavioral                     control disorders, personality disorders,
                             disorders, together with services           paraphilias, and other Mental Illnesses
                             for remedial education including            that will not substantially improve beyond
                             evaluation or treatment of                  the current level of functioning, or that
                             learning disabilities, minimal              are not subject to favorable modification
                             brain dysfunction, developmental            or management according to prevailing
                             and learning disorders,                     national standards of clinical practice, as
                             behavioral training, and cognitive          reasonably determined by the Mental
                             rehabilitation. This includes               Health/ Substance Abuse Designee.
                             services, treatment, or                     (Three plans used this language.)
                             educational testing and training
                             related to behavioral (conduct)
                             problems, learning disabilities, or
                             developmental delays.
                         •   Treatments for the primary
                             diagnoses of learning disabilities,
                             conduct and impulse control
                             disorders, personality disorders,
                             and paraphilias.
Court-ordered            •   Court-ordered evaluation or             •   Court-mandated treatment or treatment
treatments/treatments        treatment, or treatment that is a           that is a condition of parole or probation
for the incarcerated         condition of parole or probation            or in lieu of sentencing.
                             or in lieu of sentencing, such as       •   Any court-ordered treatment or therapy,
                             psychiatric evaluation or therapy.          or any treatment or therapy ordered as a
                         •   Treatment provided in connection            condition of parole, probation, or custody
                             with services for individuals who           or visitation evaluations unless Medically
                             are presently incarcerated,                 Necessary and otherwise covered under
                             confined, or committed to a local           this policy or agreement. (Four plans
                             correctional facility or prison, or a       used this language.)
                             custodial facility for youth            •   Charges for services, treatment, or care
                             operated by the office of children          of any kind of Chemical Dependency if
                             and family services, unless                 the participant is convicted in any court of
                             authorized by the Mental                    law and is required by the court, or
                             Health/Substance Use Disorder               arranges in lieu of conviction, to undergo
                             Designee.                                   care or treatment as an alternative to, or
                                                                         in addition to, a fine or imprisonment.




9                                                                    GAO-12-761R Treatment Exclusions
Enclosure

                                           Details of responses on treatment exclusions
Treatment exclusion     2011 or 2010 Plan Year                      2008 Plan Year
Court-ordered           •   Any court-ordered treatment or          •   Court-ordered psychiatric or substance
treatments/treatments       therapy, or any treatment or                abuse treatment except when certified by
for the incarcerated        therapy ordered as a condition of           (the plan) as medically necessary.
(cont.)                     parole, probation, or custody or        •   Counseling, studies, services, or
                            visitation evaluations unless               confinements ordered by a court or law
                            Medically Necessary and                     enforcement officer that are not
                            otherwise covered under this                determined to be medically necessary by
                            policy or agreement. (Five plans            the Plan Administrator or its designee.
                            used this language.)
                                                                    •   Court-ordered behavioral health services.
                        •   Court-ordered psychiatric or
                            substance abuse treatment
                            except when certified by (the
                            plan) as medically necessary.
                        •   Court-ordered behavioral health
                            services.
                        •   Court-ordered examinations and
                            treatment, unless Medically
                            Necessary.
                        •   Court-ordered testing and/or
                            evaluation.
Custodial services      •   Treatment provided in connection        •   Custodial care, including but not limited
                            with services for individuals who           to, geriatric day care. (Three plans used
                            are presently incarcerated,                 this language.)
                            confined, or committed to a local       •   Custodial care.
                            correctional facility or prison, or a
                            custodial facility for youth            •   Custodial or domiciliary care.
                            operated by the office of children
                            and family services, unless
                            authorized by the Mental
                            Health/Substance Use Disorder
                            Designee.
                        •   Custodial care, including but not
                            limited to, geriatric day care.
                            (Four plans use this language.)
                        •   Custodial care. (Two plans use
                            this language.)
                        •   Nonmedical counseling or
                            ancillary services, including but
                            not limited to, Custodial Services,
                            education, training, vocational
                            rehabilitation, behavioral training,
                            biofeedback, neurofeedback,
                            hypnosis, sleep therapy,
                            employment counseling, back
                            school, return-to-work services,
                            work hardening programs, driving
                            safety, and services training,
                            educational therapy, or other
                            nonmedical ancillary services for
                            learning disabilities,
                            developmental delays, autism, or
                            mental retardation.




10                                                                  GAO-12-761R Treatment Exclusions
Enclosure

                                        Details of responses on treatment exclusions
Treatment exclusion   2011 or 2010 Plan Year                    2008 Plan Year
Custodial services    •   Nonmedical counseling or
(cont.)                   ancillary services, including but
                          not limited to, Custodial Services,
                          education, training, vocational
                          rehabilitation, biofeedback,
                          neurofeedback, hypnosis, sleep
                          therapy, employment counseling,
                          back school, return-to-work
                          services, work hardening
                          programs, and driving safety.
                      •   Custodial or domiciliary care.
Developmental         •   Learning disabilities and             •   Developmental disorders, including but
disorder/                 developmental delays.                     not limited to, developmental reading
disabilities/delays   •   Developmental disorders,                  disorders, developmental arithmetic
                          including but not limited to,             disorders, developmental language
                          developmental reading disorders,          disorders, or developmental articulation
                          developmental arithmetic                  disorders. (Four plans used this
                          disorders, developmental                  language.)
                          language disorders, or                •   Autism and Other Pervasive
                          developmental articulation                Developmental Disorders (PDD).
                          disorders. (Five plans use this       •   Expenses for nonmedical ancillary
                          language.)                                services and treatment related to
                      •   Educational services and                  learning disabilities, developmental
                          treatment of behavioral                   delays, autism, or mental retardation.
                          disorders, together with services
                          for remedial education including
                          evaluation or treatment of
                          learning disabilities, minimal
                          brain dysfunction, developmental
                          and learning disorders,
                          behavioral training, and cognitive
                          rehabilitation. This includes
                          services, treatment, or
                          educational testing and training
                          related to behavioral (conduct)
                          problems, learning disabilities, or
                          developmental delays.
                      •   Educational therapy or other
                          nonmedical ancillary services for
                          learning disabilities,
                          developmental delays, autism, or
                          mental retardation.
                      •   Behavioral training and services,
                          educational therapy, or other
                          nonmedical ancillary services for
                          learning disabilities,
                          developmental delays, or mental
                          retardation are also excluded
                          except as specified in the Severe
                          Mental Illness of a Member of
                          any Age and Serious Emotional
                          Disturbances of a Child section
                          of Section IV.
                      •   Treatment related to learning
                          disabilities, developmental
                          delays, autism, or mental
                          retardation.




11                                                              GAO-12-761R Treatment Exclusions
Enclosure

                                           Details of responses on treatment exclusions
Treatment exclusion      2011 or 2010 Plan Year                    2008 Plan Year
Developmental reading,   •   Developmental disorders,              •   Developmental disorders, including but
arithmetic, and              including but not limited to,             not limited to, developmental reading
language disorders           developmental reading disorders,          disorders, developmental arithmetic
                             developmental arithmetic                  disorders, developmental language
                             disorders, developmental                  disorders, or developmental articulation
                             language disorders, or                    disorders. (Four plans used this
                             developmental articulation                language.)
                             disorders. (Five plans use this
                             language.)
Educational testing      •   Learning disabilities and             •   Academic or educational testing,
                             developmental delays. Those for           counseling.
                             or related to services, treatment,
                             educational testing, or training
                             related to learning disabilities or
                             developmental delays.
                         •   Educational services and
                             treatment of behavioral
                             disorders, together with services
                             for remedial education, including
                             evaluation or treatment of
                             learning disabilities, minimal
                             brain dysfunction, developmental
                             and learning disorders,
                             behavioral training, and cognitive
                             rehabilitation. This includes
                             services, treatment, or
                             educational testing and training
                             related to behavioral (conduct)
                             problems, learning disabilities, or
                             developmental delays.
Experimental/            •   Experimental or Investigational       •   Experimental or investigational therapies.
investigational              Care, as determined by (the
                             plan), including any charges for
                             related services or supplies
                             furnished in connection with
                             Experimental or Investigational
                             Care.
                         •   Experimental or investigational
                             therapies.
                         •   Services or supplies for the
                             diagnosis or treatment of Mental
                             Illness, alcoholism, or substance
                             use disorders that, in the
                             reasonable judgment of the
                             Mental Health/ Substance Use
                             Disorder Administrator, are any
                             of the following: Not consistent
                             with generally accepted
                             standards of medical practice for
                             the treatment of such conditions.
                             Not consistent with services
                             backed by credible research
                             soundly demonstrating that the
                             services or supplies will have a
                             measurable and beneficial health
                             outcome, and therefore
                             considered experimental.




12                                                                 GAO-12-761R Treatment Exclusions
Enclosure

                                        Details of responses on treatment exclusions
Treatment exclusion   2011 or 2010 Plan Year                     2008 Plan Year
Feeding disorders     •   Mental Health Services as              •   None
                          treatment for a primary diagnosis
                          of insomnia and other sleep
                          disorders, sexual dysfunction
                          disorders, feeding disorders,
                          neurological disorders, and other
                          disorders with a known physical
                          basis.
                      •   Psychotherapy or counseling
                          services for feeding and eating
                          disorder in early childhood and
                          infancy, tic disorder, except for
                          Tourette disorder, elimination
                          disorder, mental disorder due to
                          general medical condition, sexual
                          function disorder, sleep disorder,
                          medication-induced movement
                          disorder, and nicotine
                          dependence unless specifically
                          covered in the contract.
Hypnosis              •   Nonmedical counseling or               •   Hypnosis.
                          ancillary services, including but
                          not limited to, Custodial Services,
                          education, training, vocational
                          rehabilitation, behavioral training,
                          biofeedback, neurofeedback,
                          hypnosis, sleep therapy,
                          employment counseling, back
                          school, return-to-work services,
                          work hardening programs, driving
                          safety, and services training,
                          educational therapy or other
                          nonmedical ancillary services for
                          learning disabilities,
                          developmental delays, autism, or
                          mental retardation.
                      •   Nonmedical counseling or
                          ancillary services, including but
                          not limited to, Custodial Services,
                          education, training, vocational
                          rehabilitation, biofeedback,
                          neurofeedback, hypnosis, sleep
                          therapy, employment counseling,
                          back school, return-to-work
                          services, work hardening
                          programs, and driving safety.
                      •   Hypnosis or regressive hypnotic
                          techniques.
                      •   Treatment of nicotine habit or
                          addiction, including but not
                          limited to, nicotine patches,
                          hypnosis, smoking cessation
                          classes, or tapes.
                      •   Hypnosis.
I.Q. testing          •   I.Q. testing. (Five plans used this    •   I.Q. testing. (Four plans used this
                          language.)                                 language.)




13                                                               GAO-12-761R Treatment Exclusions
Enclosure

                                          Details of responses on treatment exclusions
Treatment exclusion     2011 or 2010 Plan Year                     2008 Plan Year
Learning disabilities   •   Learning disabilities and              •   Charges for education, learning
                            developmental delays.                      disabilities, job training, behavior
                        •   Educational rehabilitation or              problems, or attention deficit disorders
                            treatment of learning disabilities,        whether or not provided by a facility that
                            regardless of the setting in which         also provides medical or Psychiatric
                            such services are provided.                treatment.
                        •   Educational services and               •   Conditions related to behavior problems
                            treatment of behavioral                    or learning disabilities, except as may be
                            disorders, together with services          required by law with respect to the
                            for remedial education, including          treatment of biologically-based mental
                            evaluation or treatment of                 illness.
                            learning disabilities, minimal         •   Educational rehabilitation or treatment of
                            brain dysfunction, developmental           learning disabilities, regardless of the
                            and learning disorders,                    setting in which such services are
                            behavioral training, and cognitive         provided.
                            rehabilitation. This includes
                            services, treatment, or                •   Service or care related to the educational
                            educational testing and training           treatment of behavioral disorders
                            related to behavioral (conduct)            together with services for remedial
                            problems, learning disabilities, or        education, including learning disabilities,
                            developmental delays.                      minimal brain dysfunction, development
                                                                       and learning disorders, behavioral
                        •   Treatment for the primary                  training, and cognitive rehabilitation.
                            diagnoses of learning disabilities,
                            conduct and impulse control            •   Social adjustment counseling, expenses
                            disorders, personality disorders,          for nonmedical ancillary services and
                            and paraphilias.                           treatment related to learning disabilities,
                                                                       developmental delays, autism, or mental
                        •   Behavioral problems and                    retardation.
                            learning disabilities. Charges for
                            education, learning disabilities,
                            job training, behavioral problems
                            or attention deficit disorders
                            whether or not provided by a
                            facility that also provides medical
                            or psychiatric treatment.
                        •   Nonmedical counseling or
                            ancillary services, including but
                            not limited to, Custodial Services,
                            education, training, vocational
                            rehabilitation, behavioral training,
                            biofeedback, neurofeedback,
                            hypnosis, sleep therapy,
                            employment counseling, back
                            school, return-to-work services,
                            work hardening programs, driving
                            safety, and services, training,
                            educational therapy, or other
                            nonmedical ancillary services for
                            learning disabilities,
                            developmental delays, autism, or
                            mental retardation.




14                                                                 GAO-12-761R Treatment Exclusions
Enclosure

                                          Details of responses on treatment exclusions
Treatment exclusion     2011 or 2010 Plan Year                     2008 Plan Year
Learning disabilities   •   For any care that extends
(cont.)                     beyond traditional medical
                            management for autistic disease
                            of childhood, Pervasive
                            Development Disorders,
                            Attention Deficit Disorder,
                            learning disabilities, behavioral
                            problems, or mental retardation.
                        •   Behavioral training and services,
                            educational therapy or other
                            nonmedical ancillary services for
                            learning disabilities,
                            developmental delays, or mental
                            retardation are also excluded
                            except as specified in the Severe
                            Mental Illness of a Member of
                            any Age and Serious Emotional
                            Disturbances of a Child section
                            of Section IV.
                        •   Expenses for nonmedical
                            ancillary services and treatment
                            related to learning disabilities.
Marital therapy/        •   Marriage therapy. (Two plans           •   Marital counseling, relationship
counseling                  used this language.)                       counseling, family counseling except as
                        •   Marriage counseling.                       described in this Summary Plan
                                                                       Document, or other similar counseling or
                        •   Marriage and family counseling             training services.
                            without a behavioral health
                            diagnosis.                             •   Marital therapy.
                                                                   •   Marriage counseling.
                                                                   •   Marital counseling.
Mental retardation      •   Nonmedical counseling or               •   Mental retardation or mental conditions
                            ancillary services, including but          that, according to generally accepted
                            not limited to, Custodial Services,        professional standards, are not
                            education, training, vocational            amenable to favorable modification,
                            rehabilitation, behavioral training,       except for initial evaluation, diagnosis, or
                            biofeedback, neurofeedback,                crisis intervention.
                            hypnosis, sleep therapy,               •   Services and supplies which are
                            employment counseling, back                rendered in connection with mental
                            school, return-to-work services,           illnesses not classified in the
                            work hardening programs, driving           International Classification of Diseases of
                            safety, and services, training,            the U.S. Department of Health and
                            educational therapy, or other              Human Services or extended beyond the
                            nonmedical ancillary services for          period necessary for evaluation and
                            learning disabilities,                     diagnosis of learning and behavioral
                            developmental delays, autism, or           disabilities or for mental retardation.
                            mental retardation.




15                                                                 GAO-12-761R Treatment Exclusions
Enclosure

                                        Details of responses on treatment exclusions
Treatment exclusion   2011 or 2010 Plan Year                    2008 Plan Year
Mental retardation    •   Services and supplies which are       •   Expenses for nonmedical ancillary
(cont.)                   rendered in connection with               services and treatment related to
                          mental illnesses not classified in        learning disabilities, developmental
                          the International Classification of       delays, autism, or mental retardation.
                          diseases of the U.S. Department
                          of Health and Human Services;
                          or extended beyond the period
                          necessary for evaluation and
                          diagnosis of learning and
                          behavioral disabilities or for
                          mental retardation. (Two plans
                          used this language.)
                      •   For any care that extends
                          beyond traditional medical
                          management for autistic disease
                          of childhood, Pervasive
                          Development Disorders,
                          Attention Deficit Disorder,
                          learning disabilities, behavioral
                          problems, or mental retardation.
                      •   Behavioral training and services,
                          educational therapy or other
                          nonmedical ancillary services for
                          learning disabilities,
                          developmental delays, or mental
                          retardation are also excluded
                          except as specified in the Severe
                          Mental Illness of a Member of
                          any Age and Serious Emotional
                          Disturbances of a Child section
                          of Section IV.
                      •   Services related to mental
                          retardation.
                      •   Expenses for nonmedical
                          ancillary services and treatment
                          related to learning disabilities,
                          developmental delays, autism, or
                          mental retardation.
Organic mental        •   Treatment of disorders which          •   Treatment of disorders which have been
disorders                 have been diagnosed as organic            diagnosed as organic mental disorders
                          mental disorders associated with          associated with permanent dysfunction of
                          permanent dysfunction of the              the brain. (Four plans used this
                          brain. (Five plans used this              language.)
                          language).                            •   Treatment of organic mental disorders
                      •   For treatment of sexual                   associated with permanent dysfunction of
                          dysfunction not related to organic        the brain except for acute exacerbations
                          disease except for sexual                 of the condition.
                          dysfunction resulting from an
                          injury.
Primal therapy        •   Therapies that do not meet            •   Therapies that do not meet national
                          national standards for mental             standards for mental health professional
                          health professional practice,             practice, including but not limited to,
                          including but not limited to,             Erhard/The Forum, primal therapy,
                          Erhard/The Forum, primal                  rolfing, sensitivity training, bioenergetic
                          therapy, rolfing, sensitivity             therapy, or crystal healing therapy.
                          training, bioenergetic therapy, or
                          crystal healing therapy.




16                                                              GAO-12-761R Treatment Exclusions
Enclosure

                                           Details of responses on treatment exclusions
Treatment exclusion      2011 or 2010 Plan Year                   2008 Plan Year
Primal therapy (cont.)   •   Treatment modalities that have
                             not been incorporated into the
                             commonly accepted therapeutic
                             repertoire as determined by
                             broad-based professional
                             consensus, such as primal
                             therapy, rolfing or structural
                             integration, bioenergetic therapy,
                             and obesity control therapy.
Psychological testing    •   Psychological testing when not       •   Psychological testing when not medically
                             medically necessary.                     necessary.
                         •   Psychological testing on children    •   Psychological testing on children
                             requested by or for a school             requested by or for a school system.
                             system. (Two plans used this             (Two plans used this language.)
                             language.)                           •   Psychological testing, except when
                         •   Psychological testing, except            precertified as medically necessary by
                             when precertified as medically           (the plan).
                             necessary by (the plan).
                         •   Psychological testing. (Two plans
                             used this language.)
Residential treatment    •   Residential Treatment Centers        •   Residential Treatment Centers used for
facility                     used for the treatment of any            the treatment of any condition other than
                             condition other than Alcoholism          Alcoholism and/or Substance Abuse.
                             and/or Substance Abuse.              •   Residential treatment services.
                         •   Mental Health Residential            •   Covered expenses for residential
                             Treatment.                               treatment provided in a residential
                         •   Covered services in a residential        treatment facility when the total phase of
                             treatment facility, provided in a        treatment has not been completed by
                             residential treatment facility,          you.
                             when the member fails to
                             complete that phase of
                             treatment.
                         •   Residential Care by a Residential
                             Treatment Facility.
                         •   Necessary services such as
                             vocational programs or
                             employment counseling
                             residential treatment program.
                         •   Covered expense does not
                             include charges for inpatient or
                             outpatient services rendered in a
                             residential treatment facility.
Rolfing/structural       •   Therapies that do not meet           •   Therapies that do not meet national
integration                  national standards for mental            standards for mental health professional
                             health professional practice,            practice, including but not limited to,
                             including but not limited to,            Erhard/The Forum, primal therapy,
                             Erhard/The Forum, primal                 rolfing, sensitivity training, bioenergetic
                             therapy, rolfing, sensitivity            therapy, or crystal healing therapy.
                             training, bioenergetic therapy, or
                             crystal healing therapy.




17                                                                GAO-12-761R Treatment Exclusions
Enclosure

                                           Details of responses on treatment exclusions
Treatment exclusion      2011 or 2010 Plan Year                   2008 Plan Year
Rolfing/structural       •   Treatment modalities that have
integration (cont.)          not been incorporated into the
                             commonly accepted therapeutic
                             repertoire as determined by
                             broad-based professional
                             consensus, such as primal
                             therapy, rolfing or structural
                             integration, bioenergetic therapy,
                             and obesity control therapy.
Sex change/transsexual   •   Sex changes. Care, services, or      •   Care, services, or treatment of
surgery                      treatment for noncongenital              transsexualism, gender dysphoria or
                             transsexualism, gender                   sexual reassignment or change,
                             dysphoria, or sexual                     including medications, implants, hormone
                             reassignment or change.                  therapy, surgery, medical, or psychiatric
                         •   Transsexual surgery, including           treatment.
                             medical or psychological             •   For any treatment of either gender
                             counseling and hormonal therapy          leading to or in connection with
                             in preparation for, or subsequent        transsexual surgery, gender
                             to, any such surgery.                    transformation, sexual dysfunction, or
                         •   For any treatment of either              sexual inadequacy, including erectile
                             gender leading to or in                  dysfunction and/or impotence, even if
                             connection with transsexual              related to a medical condition.
                             surgery, gender transformation,
                             sexual dysfunction, or sexual
                             inadequacy, including erectile
                             dysfunction and/or impotence,
                             even if related to a medical
                             condition.
                         •   For any treatment leading to or in
                             connection with transsexual
                             surgery except for illness or
                             injury resulting from such
                             surgery.
                         •   Sex changes.
                         •   Transsexual surgery and related
                             services.
                         •   Sex changes services,
                             regardless of any diagnosis of
                             gender role or psychosexual
                             orientation problems.
Sex counseling           •   Treatment for codependency, or       •   Sex counseling. (Two plans used this
                             sex counseling.                          language.)
                         •   Sex counseling.
Sexual dysfunction/      •   Any services, supplies,              •   For any treatment of either gender
deviation                    medications, or drugs for the            leading to or in connection with
                             treatment of male or female              transsexual surgery, gender
                             sexual dysfunction such as, but          transformation, sexual dysfunction, or
                             not limited to, treatment of             sexual inadequacy, including erectile
                             erectile dysfunction (including          dysfunction and/or impotence, even if
                             penile implants), anorgasmia,            related to a medical condition.
                             and premature ejaculation.




18                                                                GAO-12-761R Treatment Exclusions
Enclosure

                                        Details of responses on treatment exclusions
Treatment exclusion   2011 or 2010 Plan Year                   2008 Plan Year
Sexual dysfunction/   •   Mental Health Services as            •   Treatment of sexual dysfunction or
deviation (cont.)         treatment for a primary diagnosis        inadequacies including therapy, supplies,
                          of insomnia and other sleep              or counseling.
                          disorders, sexual dysfunction
                          disorders, feeding disorders,
                          neurological disorders, and other
                          disorders with a known physical
                          basis.
                      •   Services for sexual deviation and
                          dysfunction.
                      •   For any treatment of either
                          gender leading to or in
                          connection with transsexual
                          surgery, gender transformation,
                          sexual dysfunction, or sexual
                          inadequacy, including erectile
                          dysfunction and/or impotence,
                          even if related to a medical
                          condition.
                      •   For treatment of sexual
                          dysfunction not related to organic
                          disease except for sexual
                          dysfunction resulting from an
                          injury.
                      •   Sexual function disorder.
                      •   Charges for treatment of sexual
                          dysfunction except as stated.
                      •   Treatment of sexual dysfunction.
                      •   Your coverage does not include
                          benefits for services for sex
                          transformation or sexual
                          dysfunction.
Sleep disorders/      •   Mental Health Services as            •   Mental Health Services as treatment for
insomnia                  treatment for a primary diagnosis        insomnia and other sleep disorders,
                          of insomnia and other sleep              neurological disorders, and other
                          disorders, sexual dysfunction            disorders with a known physical basis.
                          disorders, feeding disorders,            (Three plans used this language.)
                          neurological disorders, and other
                          disorders with a known physical
                          basis.
                      •   Sleep disorders. (Two plans used
                          this language.)
Smoking cessation/    •   Smoking cessation. Care and          •   Services or supplies furnished for
tobacco addiction         treatment for smoking cessation          diagnosis or treatment of alcoholism,
                          programs, including smoking              controlled substance abuse, chemical
                          deterrent products, unless               dependency, tobacco addiction, or
                          medically necessary due to a             codependency treatment for any of the
                          severe active lung Illness such          above except as provided in the
                          as emphysema or asthma.                  Schedule of Benefits.




19                                                             GAO-12-761R Treatment Exclusions
Enclosure

                                        Details of responses on treatment exclusions
Treatment exclusion   2011 or 2010 Plan Year                     2008 Plan Year
Smoking cessation/    •   Stand-alone multidisciplinary          •   Smoking cessation.
tobacco addiction         smoking cessation programs
(cont.)                   unless medically necessary as
                          determined by us.
                      •   Services or supplies furnished for
                          diagnosis or treatment of
                          alcoholism, controlled substance
                          abuse, chemical dependency,
                          tobacco addiction, or
                          codependency treatment for any
                          of the above except as provided
                          in the Schedule of Benefits.
                      •   Additionally, we will not cover
                          any “V code” diagnoses except
                          the following when medically
                          necessary: parent-child relational
                          problems for children 5 years of
                          age or younger, neglect or abuse
                          of a child for children 5 years of
                          age or younger, and
                          bereavement for children 5 years
                          of age or younger, tobacco
                          addiction treatment.
                      •   Smoking Cessation. (Two plans
                          used this language.)
                      •   Treatment of nicotine habit or
                          addiction, including but not
                          limited to, nicotine patches,
                          hypnosis, smoking cessation
                          classes, or tapes.
                      •   Your coverage does not include
                          benefits for smoking cessation
                          programs not affiliated with us.
Special education     •   Special education, school testing      •   Special education, school testing or
                          or evaluations, counseling,                evaluations, counseling, therapy, or care
                          therapy, or care for learning              for learning deficiencies or behavioral
                          deficiencies or behavioral                 problems. This applies whether or not
                          problems.                                  associated with manifest mental illness
                      •   Special education, including               or other disturbances.
                          lessons in sign language to
                          instruct a member whose ability
                          to speak has been lost or
                          impaired, to function without that
                          ability, are not covered.
                      •   Remedial or special education
                          services. (Two plans use this
                          language.)
V-code                •   Mental Health Services as                  These include relational problems such
                          treatments for V-code conditions           as: parent-child conflicts; problems
                          as listed within the current edition       related to abuse or neglect when
                          of the Diagnostic and Statistical          intervention is focused on the
                          Manual of the American                     perpetrator; and situations not
                          Psychiatric Association.                   attributable to a diagnosable disorder,
                          (Two plans used this language.)            including bereavement, academic,
                                                                     occupational, religious, and spiritual
                                                                     problems.




20                                                               GAO-12-761R Treatment Exclusions
Enclosure

                                                                Details of responses on treatment exclusions
 Treatment exclusion                 2011 or 2010 Plan Year                         2008 Plan Year
 V-code (cont.)                      •      Additionally, we will not cover
                                            any “V code” diagnoses except
                                            the following when medically
                                            necessary: parent-child relational
                                            problems for children 5 years of
                                            age or younger, neglect or abuse
                                            of a child for children 5 years of
                                            age or younger, and
                                            bereavement for children 5 years
                                            of age or younger, tobacco
                                            addiction treatment.
 Vocational/religious                •      Vocational or religious                 •   Vocational or religious counseling. (Four
 (pastoral) counseling                      counseling. (Six plans use this             plans used this language.)
                                            language.)                              •   Conditions classified as V-codes in the
                                     •      Vocational rehabilitation. (Two             most current edition of the Diagnostic
                                            plans used this language.)                  and Statistical Manual of Mental
                                     •      Vocational and recreational                 Disorders of the American Psychiatric
                                            activities. (Two plans use this             Association. These include relational
                                            language.)                                  problems such as: parent-child conflicts;
                                                                                        problems related to abuse or neglect
                                     •      Vocational and educational                  when intervention is focused on the
                                            training and/or services.                   perpetrator; and situations not
                                     •      Referral for nonmedically                   attributable to a diagnosable disorder,
                                            necessary services such as                  including bereavement, academic,
                                            vocational programs or                      occupational, religious, and spiritual
                                            employment counseling                       problems.
                                            residential treatment program.
Source: GAO analysis of employers’ survey responses on health insurance coverage.




(291046)



21                                                                                  GAO-12-761R Treatment Exclusions
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