Kaiser Foundation Health Plan reaches $200 million behavioral health settlement

Photo: Basak Gurbuz Derman/Getty Images

Kaiser Foundation Health Plan, run by Kaiser Permanente, and the California Department of Managed Health Care (DMHC) have reached a $200 million settlement agreement to make significant changes to the plan's delivery of behavioral healthcare services.

The settlement agreement includes a $50 million fine and requires Kaiser Permanente to take corrective action to address deficiencies in the plan's delivery and oversight of behavioral health care to enrollees.

Kaiser Permanente has also pledged to make additional significant investments, totaling $150 million over five years, into programs to improve the delivery of behavioral health services for Californians.

WHAT'S THE IMPACT?

The agreement relates to two regulatory actions by the DMHC: an enforcement investigation and a non-routine survey, which is an investigatory survey with DMHC finding justifiable cause to investigate issues of compliance with the law.

Collectively, DMHC said, these identified several violations and deficiencies in the plan's provision of behavioral healthcare services to enrollees, including issues identified in providing timely access to care, oversight of the plan's providers and medical groups, network adequacy, conformity to mental health parity and grievances and appeals, among other issues.

The DMHC found Kaiser Permanente canceled behavioral health appointments and, in many cases, did not provide enrollees with behavioral health appointments that met timely access and clinical standards that were still required, regardless of a strike by mental health clinicians that was initiated in August of 2022.

In addition to the length of time enrollees had to wait to get appointments, the DMHC found violations in the plan's behavioral healthcare delivery system, including a shortage of contracted high-level behavioral healthcare facilities in the plan's network, inadequate oversight of the plan's medical groups in evaluating appropriate care, not making out-of-network referrals consistent with requirements under the law when in-network providers are not available, and inadequate handling of enrollee grievances.

Under the settlement agreement, Kaiser Permanente will hire an outside consultant to focus on corrective actions to help ensure enrollees receive timely access to medically necessary behavioral healthcare services. The consultant will provide expert guidance and aid Kaiser Permanente's Behavioral Health Quality Assurance program in ensuring that effective action is taken to improve care where deficiencies are identified in service areas, including accessibility, availability and continuity of care.

In addition to improving the QAP, Kaiser will be compelled to improve its procedures to ensure that its enrollees can access behavioral health appointments consistent with timely access standards. It also must improve the ability of its enrollees to access the plan's network of providers, including external contracted providers, for behavioral health services, and improve the ability of its enrollees to access out-of-network providers for behavioral health services in instances where the plan's network of providers can't offer enrollees timely care.

The health plan will also improve its grievance and appeals policies and procedures to include making sure enrollee grievances are acknowledged and responded to within the time frames required by law, and develop processes to ensure compliance with all behavioral health parity laws. This includes ensuring that enrollees receive appropriate treatment based on individualized determinations of clinical appropriateness, and regardless of the type or severity of the enrollees' behavioral health conditions.

THE LARGER TREND

While 50% of adults with a behavioral condition do not receive treatment, a robust ecosystem inclusive of early identification, along with personalized care pathways with patient to provider matching, can result in improved outcomes, according to June research published by Evernorth.

The demand for behavioral health providers continues to grow. Evernorth's analysis finds the prevalence of behavioral health conditions grew by 4% from 2021 to 2022. The analysis, which looks at anonymized and aggregated claims data of six million people from 2021 to 2022, finds that increases in prevalence vary by condition, with the largest occurring within attention-deficit hyperactive disorder (ADHD), personality disorder and autism spectrum disorder.

The data also shows that the 22% of patients with a diagnosed behavioral condition drive 41% of total healthcare spend for the entire population.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com