In recent years, several lawsuits have challenged wilderness therapy program exclusions in health plans. Not only do members typically assert a claim for benefits, alleging a denial of wilderness therapy benefits was improper under their health plan, but they also insist the plan’s exclusion that serves as the basis for the denial violates the Mental Health Parity and Addiction Equity Act (MHPAEA).
What is a Wilderness Therapy Program?
While wilderness therapy programs vary significantly, these programs typically offer a 24-hour group living environment that combines traditional behavioral health therapy with adventure/outdoor therapy. Members tend to argue these programs are merely outdoor residential treatment centers and, as such, should be approved as residential treatment and cannot be categorically excluded.
Wilderness Therapy Program Exclusions.
Like wilderness therapy programs themselves, plan exclusions also significantly vary. For example, some plans list wilderness therapy programs or camps as an excluded service without further definition. Others exclude such programs as either: (1) investigational, (2) failing to meet the definition of residential treatment centers, or (3) not one of the enumerated facilities that may bill for residential charges. Some bases, or at least the language describing the bases, for exclusion fare better than others.
For example, in reviewing a member’s claim for benefits following a plan’s denial based on a wilderness therapy program exclusion, more than one court has determined when undefined, “wilderness therapy program” is ambiguous. According to these courts, without a definition in the plan, “wilderness therapy program” could include both a therapeutic summer camp and a residential treatment center that happens to be outdoors. Once deemed ambiguous, the applicable standard of review may significantly impact a plan administrator’s ability to defend the denial because administrators carry the burden of proving the exclusion applies to the specific facility at issue. Further, undefined exclusions are more difficult to defend against parity claims. Because wilderness therapy programs tend to be only in the behavioral health space, without further definition, it is not clear such an exclusion would apply to both behavioral health and medical/surgical benefits.
Other types of wilderness therapy program exclusions have seen greater success. For example, one court recently dismissed a MHPAEA claim when a plan excluded wilderness therapy programs as investigational, relying on a medical policy that expressly applied to both behavioral health and medical/surgical benefits.
Our Take:
Based on recent decisions, health plans excluding wilderness therapy programs should (re)consider the stated basis for the exclusion in plan documents. Administrators must be able to defend the exclusion both from a benefits and parity perspective. Attorneys at Troutman can assist in reviewing plan language, as well as defending benefit denial claims resulting from these types of exclusions.