GAO-12-761R Treatment Exclusions

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

 

1

See GAO-12-63, Nov. 30, 2011.

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 

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. 
2 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.
3 GAO-12-761R Treatment Exclusions

Table 1: The Incidence of Plan Treatment Exclusions for Mental Health Conditions and Substance Use 

Disorders Among Survey Respondents

Number of times a 

treatment was listed as 

an exclusion

Percent of plans that 

excluded a treatment 

(based on number of plans 

in each year where employer 

indicated a treatment 

was excluded)

Treatment exclusion 2011 or 2010 2008 a b 2011 or 2010 2008 a

Alcoholism

b

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.
4 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 
Enclosure

5 GAO-12-761R Treatment Exclusions

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 

treatments are not considered 

mental health benefits.

• Alcohol. 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.

• Alcohol and/or Substance Abuse 

treatments are not considered mental 

health benefits.

• 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.

• For Acute Care, rehabilitative care, or 

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 

disorder

• 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.

• 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.

• None
Enclosure

6 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Autism • Educational therapy or other 

nonmedical ancillary services for 

learning disabilities, 

developmental delays, autism, or 

mental retardation.

• 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. 

• Autism and Other Pervasive 

Developmental Disorders (PDD).

• Expenses for nonmedical ancillary 

services and treatment related to 

learning disabilities, developmental 

delays, autism, 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/

problems/delays/ 

counseling/health/ 

training/services

• Special education, school testing 

or evaluations, counseling, 

therapy or care for learning 

deficiencies or behavioral 

problems.

• 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.

• Educational/behavioral services 

that are focused on primarily 

building skills and capabilities in 

communication, social 

interaction, and learning.

• Special education, school testing or 

evaluations, counseling, therapy or care 

for learning deficiencies or behavioral 

problems.

• Service or care related to the educational 

treatment of behavioral disorders.

• 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.

• 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.
Enclosure

7 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Behavioral disorders/

problems/delays/ 

counseling/health/ 

training/services (cont.)

• 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. 

• 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.
Enclosure

8 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Bioenergetic therapy • Therapies that do not meet 

national standards for mental 

health professional practice, 

including but not unlimited to, 

Erhard/The Forum, primal 

therapy, rolfing, sensitivity 

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.

• Therapies that do not meet national 

standards for mental health professional 

practice, including but not limited to, 

Erhard/The Forum, primal therapy, 

rolfing, sensitivity training, bioenergetic 

therapy, or crystal healing therapy.

Biofeedback • 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.

• 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.) 

• Biofeedback. (Two plans used this 

language.)

Borderline intellectual 

functioning

• Counseling for borderline 

intellectual functioning. (Five 

plans used this language.) 

• Counseling for borderline intellectual 

functioning. (Four plans used this 

language.) 

“Conditions not in the 

Diagnostic and 

Statistical Manual” 

• Services performed in connection 

with conditions not classified in 

the current edition of the 

Diagnostic and Statistical Manual

of the American Psychiatric 

Association. (Three plans used 

this language.)

• Services performed in connection with 

conditions not classified in the current 

edition of the Diagnostic and Statistical 

Manual of the American Psychiatric 

Association. (Three plans used this 

language.)
Enclosure

9 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

“Conditions not in the 

Diagnostic and 

Statistical Manual” 

(cont.)

• Conditions which (the plan) determines 

to lack a recognizable III-R classification 

in the most current edition of the 

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 

disorders

• 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.

• Treatments for the primary 

diagnoses of learning disabilities, 

conduct and impulse control 

disorders, personality disorders, 

and paraphilias.

• Treatment for conduct and impulse 

control disorders, personality disorders, 

paraphilias, and other Mental Illnesses 

that will not substantially improve beyond 

the current level of functioning, or that 

are not subject to favorable modification 

or management according to prevailing 

national standards of clinical practice, as 

reasonably determined by the Mental

Health/ Substance Abuse Designee. 

(Three plans used this language.)

Court-ordered 

treatments/treatments 

for the incarcerated

• Court-ordered evaluation or 

treatment, or treatment that is a 

condition of parole or probation 

or in lieu of sentencing, such as 

psychiatric evaluation or therapy.

• Treatment provided in connection 

with services for individuals who 

are presently incarcerated, 

confined, or committed to a local 

correctional facility or prison, or a 

custodial facility for youth 

operated by the office of children 

and family services, unless 

authorized by the Mental 

Health/Substance Use Disorder 

Designee.

• Court-mandated treatment or treatment 

that is a condition of parole or probation 

or in lieu of sentencing.

• Any court-ordered treatment or therapy, 

or any treatment or therapy ordered as a 

condition of parole, probation, or custody 

or visitation evaluations unless Medically 

Necessary and otherwise covered under 

this policy or agreement. (Four plans 

used this language.)

• Charges for services, treatment, or care 

of any kind of Chemical Dependency if 

the participant is convicted in any court of 

law and is required by the court, or 

arranges in lieu of conviction, to undergo 

care or treatment as an alternative to, or 

in addition to, a fine or imprisonment.
Enclosure

10 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Court-ordered 

treatments/treatments 

for the incarcerated

(cont.)

• Any court-ordered treatment or 

therapy, or any treatment or 

therapy ordered as a condition of 

parole, probation, or custody or 

visitation evaluations unless 

Medically Necessary and 

otherwise covered under this 

policy or agreement. (Five plans 

used this language.)

• 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.

• Court-ordered psychiatric or substance 

abuse treatment except when certified by 

(the plan) as medically necessary.

• Counseling, studies, services, or 

confinements ordered by a court or law 

enforcement officer that are not 

determined to be medically necessary by 

the Plan Administrator or its designee.

• Court-ordered behavioral health services.

Custodial services • Treatment provided in connection 

with services for individuals who 

are presently incarcerated, 

confined, or committed to a local 

correctional facility or prison, or a 

custodial facility for youth 

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.)

• Custodial care, including but not limited 

to, geriatric day care. (Three plans used 

this language.)

• Custodial care.

• Custodial or domiciliary care.

• 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.
Enclosure

11 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Custodial services

(cont.)

• 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.

• Custodial or domiciliary care.

Developmental 

disorder/ 

disabilities/delays

• Learning disabilities and 

developmental delays.

• Developmental disorders, 

including but not limited to, 

developmental reading disorders, 

developmental arithmetic 

disorders, developmental 

language disorders, or 

developmental articulation 

disorders. (Five plans use this 

language.)

• 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.

• Educational therapy or other 

nonmedical ancillary services for 

learning disabilities, 

developmental delays, autism, or 

mental retardation.

• Developmental disorders, including but 

not limited to, developmental reading 

disorders, developmental arithmetic 

disorders, developmental language 

disorders, or developmental articulation 

disorders. (Four plans used this 

language.)

• Autism and Other Pervasive 

Developmental Disorders (PDD).

• Expenses for nonmedical ancillary 

services and treatment related to 

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.
Enclosure

12 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Developmental reading, 

arithmetic, and 

language disorders

• Developmental disorders, 

including but not limited to, 

developmental reading disorders, 

developmental arithmetic

disorders, developmental 

language disorders, or 

developmental articulation 

disorders. (Five plans use this 

language.)

• Developmental disorders, including but 

not limited to, developmental reading 

disorders, developmental arithmetic 

disorders, developmental language 

disorders, or developmental articulation 

disorders. (Four plans used this 

language.) 

Educational testing • Learning disabilities and 

developmental delays. Those for 

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.

• Academic or educational testing, 

counseling.

Experimental/ 

investigational

• Experimental or 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.

• 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.
Enclosure

13 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Feeding disorders • Mental Health Services as 

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.

• None 

Hypnosis • 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.

• 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.

• Hypnosis.

I.Q. testing • I.Q. testing. (Five plans used this 

language.) 

• I.Q. testing. (Four plans used this 

language.)
Enclosure

14 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Learning disabilities • Learning disabilities and 

developmental delays.

• Educational rehabilitation or 

treatment of learning disabilities, 

regardless of the setting in which 

such services are provided.

• Charges for education, learning 

disabilities, job training, behavior 

problems, or attention deficit disorders 

whether or not provided by a facility that 

also provides medical or Psychiatric 

treatment.

• 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.

• Treatment for the primary 

diagnoses of learning disabilities, 

conduct and impulse control 

disorders, personality disorders, 

and paraphilias.

• Conditions related to behavior problems 

or learning disabilities, except as may be 

required by law with respect to the 

treatment of biologically-based mental 

illness.

• Educational rehabilitation or treatment of 

learning disabilities, regardless of the 

setting in which such services are 

provided.

• Service or care related to the educational 

treatment of behavioral disorders 

together with services for remedial 

education, including learning disabilities, 

minimal brain dysfunction, development 

and learning disorders, behavioral 

training, and cognitive rehabilitation.

• Social adjustment counseling, expenses 

for nonmedical ancillary services and 

treatment related to learning disabilities, 

developmental delays, autism, or mental 

retardation. • 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.

• 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.
Enclosure

15 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Learning disabilities

(cont.)

• 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.

• Expenses for nonmedical 

ancillary services and treatment 

related to learning disabilities.

Marital therapy/ 

counseling

• Marriage therapy. (Two plans 

used this language.)

• Marriage counseling.

• Marriage and family counseling 

without a behavioral health 

diagnosis.

• Marital counseling, relationship 

counseling, family counseling except as 

described in this Summary Plan 

Document, or other similar counseling or 

training services.

• Marital therapy.

• Marriage counseling.

• Marital counseling.

Mental retardation • 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.

• Mental retardation or mental conditions 

that, according to generally accepted 

professional standards, are not 

amenable to favorable modification, 

except for initial evaluation, diagnosis, or 

crisis intervention.

• 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.
Enclosure

16 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Mental retardation

(cont.)

• 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.

• Expenses for nonmedical ancillary 

services and treatment related to 

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.

• Services related to mental 

retardation.

• Expenses for nonmedical 

ancillary services and treatment 

related to learning disabilities, 

developmental delays, autism, or 

mental retardation.

Organic mental 

disorders

• Treatment of disorders which 

have been diagnosed as organic 

mental disorders associated with 

permanent dysfunction of the 

brain. (Five plans used this 

language).

• For treatment of sexual 

dysfunction not related to organic 

disease except for sexual 

dysfunction resulting from an 

injury.

• Treatment of disorders which have been 

diagnosed as organic mental disorders 

associated with permanent dysfunction of 

the brain. (Four plans used this 

language.)

• Treatment of organic mental disorders 

associated with permanent dysfunction of 

the brain except for acute exacerbations 

of the condition.

Primal therapy • Therapies that do not meet 

national standards for mental 

health professional practice, 

including but not limited to, 

Erhard/The Forum, primal 

therapy, rolfing, sensitivity 

training, bioenergetic therapy, or 

crystal healing therapy.

• Therapies that do not meet national 

standards for mental health professional 

practice, including but not limited to, 

Erhard/The Forum, primal therapy, 

rolfing, sensitivity training, bioenergetic 

therapy, or crystal healing therapy.
Enclosure

17 GAO-12-761R Treatment Exclusions

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 

medically necessary.

• Psychological testing on children 

requested by or for a school 

system. (Two plans used this 

language.)

• Psychological testing, except 

when precertified as medically 

necessary by (the plan).

• Psychological testing. (Two plans 

used this language.)

• Psychological testing when not medically 

necessary.

• Psychological testing on children 

requested by or for a school system. 

(Two plans used this language.)

• Psychological testing, except when 

precertified as medically necessary by 

(the plan).

Residential treatment 

facility

• Residential Treatment Centers 

used for the treatment of any 

condition other than Alcoholism 

and/or Substance Abuse.

• Mental Health Residential 

Treatment.

• Covered services in a residential 

treatment facility, provided in a 

residential treatment facility, 

when the member fails to 

complete that phase of 

treatment.

• Residential Care by a Residential 

Treatment Facility.

• Residential Treatment Centers used for 

the treatment of any condition other than 

Alcoholism and/or Substance Abuse.

• Residential treatment services.

• Covered expenses for residential 

treatment provided in a residential 

treatment facility when the total phase of 

treatment has not been completed by 

you.

• 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 

integration

• Therapies that do not meet 

national standards for mental 

health professional practice, 

including but not limited to, 

Erhard/The Forum, primal 

therapy, rolfing, sensitivity 

training, bioenergetic therapy, or 

crystal healing therapy.

• Therapies that do not meet national 

standards for mental health professional 

practice, including but not limited to, 

Erhard/The Forum, primal therapy, 

rolfing, sensitivity training, bioenergetic 

therapy, or crystal healing therapy.
Enclosure

18 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Rolfing/structural 

integration (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.

Sex change/transsexual 

surgery

• Sex changes. Care, services, or 

treatment for noncongenital 

transsexualism, gender 

dysphoria, or sexual 

reassignment or change.

• Transsexual surgery, including 

medical or psychological 

counseling and hormonal therapy 

in preparation for, or subsequent 

to, any such surgery.

• 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.

• Care, services, or treatment of 

transsexualism, gender dysphoria or 

sexual reassignment or change, 

including medications, implants, hormone 

therapy, surgery, medical, or psychiatric 

treatment.

• 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 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.

• Sex counseling.

• Sex counseling. (Two plans used this 

language.) 

Sexual dysfunction/

deviation

• Any services, supplies, 

medications, or drugs for the 

treatment of male or female 

sexual dysfunction such as, but 

not limited to, treatment of 

erectile dysfunction (including 

penile implants), anorgasmia, 

and premature ejaculation.

• 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.
Enclosure

19 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Sexual dysfunction/

deviation (cont.)

• Mental Health Services as

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.

• Treatment of sexual dysfunction or 

inadequacies including therapy, supplies, 

or counseling.

• 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/ 

insomnia

• Mental Health Services as 

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.

• Sleep disorders. (Two plans used 

this language.) 

• Mental Health Services as treatment for 

insomnia and other sleep disorders, 

neurological disorders, and other 

disorders with a known physical basis. 

(Three plans used this language.) 

Smoking cessation/

tobacco addiction

• Smoking cessation. Care and 

treatment for smoking cessation 

programs, including smoking 

deterrent products, unless 

medically necessary due to a 

severe active lung Illness such 

as emphysema or asthma.

• 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.
Enclosure

20 GAO-12-761R Treatment Exclusions

Details of responses on treatment exclusions

Treatment exclusion 2011 or 2010 Plan Year 2008 Plan Year

Smoking cessation/

tobacco addiction

(cont.)

• Stand-alone multidisciplinary 

smoking cessation programs 

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.

• Smoking cessation.

• 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 

or evaluations, counseling, 

therapy, or care for learning 

deficiencies or behavioral 

problems.

• Special education, including 

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.)

• Special education, school testing or 

evaluations, counseling, therapy, or care 

for learning deficiencies or behavioral 

problems. This applies whether or not 

associated with manifest mental illness 

or other disturbances.

V-code • Mental Health Services as 

treatments for V-code conditions 

as listed within the current edition 

of the Diagnostic and Statistical 

Manual of the American 

Psychiatric Association. 

(Two plans used this language.)

These include relational problems such 

as: parent-child conflicts; problems 

related to abuse or neglect when 

intervention is focused on the 

perpetrator; and situations not 

attributable to a diagnosable disorder, 

including bereavement, academic, 

occupational, religious, and spiritual 

problems.
Enclosure

21 GAO-12-761R Treatment Exclusions

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 

(pastoral) counseling

• Vocational or religious 

counseling. (Six plans use this 

language.)

• Vocational rehabilitation. (Two 

plans used this language.)

• Vocational and recreational 

activities. (Two plans use this

language.)

• Vocational and educational 

training and/or services.

• Referral for nonmedically 

necessary services such as 

vocational programs or 

employment counseling 

residential treatment program.

• Vocational or religious counseling. (Four 

plans used this language.)

• Conditions classified as V-codes in the 

most current edition of the Diagnostic 

and Statistical Manual of Mental 

Disorders of the American Psychiatric 

Association. These include relational 

problems such as: parent-child conflicts; 

problems related to abuse or neglect 

when intervention is focused on the 

perpetrator; and situations not 

attributable to a diagnosable disorder, 

including bereavement, academic, 

occupational, religious, and spiritual 

problems.

Source: GAO analysis of employers’ survey responses on health insurance coverage.

(291046)
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