00
Methodology & Doc-Type Caveat
Critical for interpretation: The corpus mixes document types with very different depth. Any cross-payer comparison for Regence 2025 and Molina 2023/2024 reflects SBC-level detail only — not full coverage terms. The drift analysis found 0 genuine coverage changes; all 10 apparent changes were doc-type transitions.
| Doc Type | Pages | Words | BH Depth |
|---|---|---|---|
| Full EOC / Benefit Booklet | 60–121 | 25K–42K | Full: LOC defs, med nec criteria, PA rules, parity |
| Full Policy (Regence) | 92–98 | 39K–42K | Full: same as EOC |
| SBC (Summary of Benefits) | 2–10 | 1K–3.5K | Summary: cost-sharing only, minimal BH detail |
| SOB (Schedule of Benefits) | 7–10 | 1.6K–3.5K | Summary: cost-sharing only |
Full-depth corpus (36 docs): Kaiser all 28 plans (60–66pp EOCs) · Molina molina_2025_eoc (83pp) · Premera 2024 & 2025 booklets (101–121pp) · Regence 2024 Cascade + HSA policies (92–98pp).
A
Corpus-Wide Raw Insights
MAT Coverage
85.7%
Near-universal — ACA/MHPAEA pressure working
BH Exclusions Present
82.5%
Most plans contain at least one BH carve-out
IOP Coverage
58.7%
Missing in 41% — significant gap
PHP Coverage
55.6%
Missing in 44% — significant gap
Residential Treatment
49.2%
Missing in 51% — majority don't explicitly name it
PA Required for BH
7.9%
Low average, but payer concentration is high
MHPAEA Cited
4.8%
Only 3 docs — parity is implied, not stated
MCG / InterQual / NQTL
0%
No payer names their med nec tool in member-facing docs
Criteria opacity: No payer explicitly names their medical necessity criteria tool (MCG, InterQual, ASAM) in member-facing EOC documents. Plans reference "established clinical criteria" or "our clinical criteria" without specifying the tool. Members and providers cannot access the criteria being used to deny claims.
BH exclusions are universal: All 4 payers include BH exclusions in some form. Most common: custodial care, educational services, and "not medically necessary" catch-alls. These exclusions are the basis for a significant share of behavioral health denials.
B
Behavioral Health — Payer Comparison
2024 Cross-Payer BH Coverage (full EOC docs where available)
| Coverage Flag | Kaiser | Molina | Premera | Regence |
|---|---|---|---|---|
| PHP (Partial Hospitalization) | ✅ | SBC only* | ✅ | ✅ |
| IOP (Intensive Outpatient) | ✅ | SBC only* | ✅ | ✅ |
| Residential Treatment | ✅ | SBC only* | ✅ | ❌ |
| MAT Coverage | ✅ | ✅ | ✅ | ✅ |
| PA Required for BH | ❌ | ❌ | ✅ | ❌ |
| MHPAEA Explicitly Cited | ❌ | ❌ | ✅ | ❌ |
| ASAM Criteria Cited | ❌ | ❌ | ❌ | ✅ |
| Crisis Services | ✅ | ❌ | ✅ | ✅ |
*Molina 2024 only has SBC documents — full LOC coverage terms not verifiable without 2024 EOC.
2025 Cross-Payer BH Coverage
| Coverage Flag | Kaiser | Molina | Premera | Regence |
|---|---|---|---|---|
| PHP | ✅ | ✅ | ✅ | SBC only* |
| IOP | ✅ | ✅ | ✅ | SBC only* |
| Residential Treatment | ✅ | ✅ | ✅ | SBC only* |
| MAT Coverage | ✅ | ✅ | ✅ | ✅ |
| PA Required for BH | ❌ | ✅ | ✅ | ❌ |
| MHPAEA Cited | ❌ | ✅ | ✅ | ❌ |
| Crisis Services | ✅ | ✅ | ❌ | SBC only* |
*Regence 2025 corpus only contains SBC summaries — full policy docs not yet acquired.
Payer-Specific Findings
Kaiser
Most consistent LOC coverage — all 5 tiers across all years. No PA required for BH in any plan year or tier. Does not cite MHPAEA by name — relies on implicit parity through integrated benefit structure. Uses "established clinical criteria" without naming the tool.
Molina
2024 corpus SBC-only — full BH terms unknown. 2025 EOC is richest BH doc in corpus (83pp, dedicated MHPAEA section). Added PA requirement for BH in 2025. Explicitly covers PHP, IOP, and residential treatment.
Premera
Only payer requiring PA for BH in both 2024 and 2025 full EOCs. Only payer to cite MHPAEA explicitly in 2024 booklet. 2025 Standard Gold states "This plan complies with federal mental health parity requirements." Covers all major LOC tiers.
Regence
2024 full policies most detailed in corpus (39K–42K words). Only payer to name a med nec tool (ASAM in SUD context). Does NOT cover residential treatment in any 2024 full policy. 2025 corpus SBC-only.
B2
Year-over-Year Drift Analysis
Finding: No genuine coverage changes detected at the flag level. All 10 apparent changes in the drift analysis are doc-type transitions — comparing SBC summaries to full EOC documents. This is a methodological artifact, not a real coverage shift.
Gaps blocking clean drift analysis
Regence 2023 — archived, not in corpus. Needed for genuine 2023→2024 Regence comparison.
Regence 2025 full policy — only SBC summaries. Needed for 2024→2025 comparison.
Premera 2023 — archived, opaque doc IDs. Not publicly accessible.
Kaiser provides the cleanest multi-year comparison (EOC-to-EOC across all 3 years). A notable observation in Kaiser 2023 vs 2024/2025: "prior authorization" gains BH context mentions in 2024 onward — confirmed in Analysis C as a genuine coverage change.
B3
BH Definition Registry
Medical Necessity Language by Payer
| Payer | Years | Med Nec Language | Tool Named? |
|---|---|---|---|
| Kaiser | 2023/24/25 | "...based on established clinical criteria and may require Preauthorization..." | None |
| Molina | 2025 | Standard ACA language. Defers to plan criteria. | None |
| Premera | 2024/25 | "medically necessary and covered by the plan" — PA required for certain BH services | None |
| Regence | 2024 | "...You may request that a non-contracted Provider preauthorize services on Your behalf to determine Medical Necessity..." References ASAM in SUD context. | ASAM (SUD only) |
Level of Care Coverage
44 LOC excerpts extracted. Residential treatment is the most contested LOC tier — present in Kaiser, Molina 2025, Premera full EOCs; absent in Regence policy and Molina 2023/2024 SBCs. This aligns with OIG 2022 finding that residential is the tier with the highest national denial rates.
Parity Language
| Payer | MHPAEA Cited | Parity Statement |
|---|---|---|
| Premera 2025 | ✅ | "This plan complies with federal mental health parity requirements." |
| Molina 2025 | ✅ | Dedicated section: "Mental Health Parity and Addiction Equity Act" |
| Premera 2024 | ✅ | "This plan will comply with federal mental health parity requirements." |
| Kaiser (all years) | ❌ | No parity language — relies on integrated benefit structure |
| Regence 2024 | ❌ | Not present in full policy documents |
C
Claude API Deep Extraction
Scope: 36 full-depth documents — all Kaiser EOCs + Molina 2025 EOC + Premera 2024/2025 booklets + Regence 2024 policies.
Script:
Script:
scripts/analyze_bh_claude.py · Model: Claude Haiku · Cost: ~$0.20 total · Output: analysis/bh_deep_extraction.json
C1
Medical Necessity — Criteria Tool Discovery
Only one payer named a criteria tool — once. Kaiser referenced "KFHPWA approved clinical review criteria" in 2023 EOCs in the SUD med nec context. This language was removed in 2024 and 2025. Across all 36 full-depth documents, this is the only instance of any payer naming their criteria tool in member-facing language.
| Payer | Year | Tool Named | Language |
|---|---|---|---|
| Kaiser | 2023 | KFHPWA approved clinical review criteria | Appears in SUD med nec context |
| Kaiser | 2024/2025 | Removed | Changed to generic "established clinical criteria" |
| Molina | 2025 | None | Defers to plan criteria |
| Premera | 2024/2025 | None | References criteria without naming |
| Regence | 2024 | ASAM (SUD only) | Named in SUD context elsewhere in policy |
C2
Prior Authorization — Year-over-Year Drift (Kaiser)
This is a genuine year-over-year coverage change. Unlike the doc-type artifacts in Analysis B2, Kaiser's escalating PA requirements for BH are confirmed by verbatim language extraction. This is the most actionable denial-defense finding in the corpus.
| Year | BH-Related PA Requirements Added |
|---|---|
| 2023 | Non-emergency inpatient hospital (general) |
| 2024 | Non-emergency inpatient + Substance use disorder services (added) |
| 2025 | Non-emergency inpatient + SUD + "All residential treatment" (added, explicit) |
Kaiser 2025 verbatim: "All residential treatment, non-emergency inpatient hospital and non-emergency ambulance services require Preauthorization. Failure to obtain Preauthorization when required may result in denial of coverage for those services, and the Member may be responsible for the cost of these non-Covered services."
Premera 2025 verbatim: "All planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance use disorder). Elective admissions must have prior authorization before admission. Admission to all residential treatment programs."
Residential treatment PA now required by both Kaiser and Premera in 2025. Together these two payers cover the majority of WA individual market enrollees. Residential treatment denials for PA non-compliance will increase.
C3
Parity Language — Confirmed Corpus
| Payer | Year | MHPAEA Cited | Verbatim |
|---|---|---|---|
| Premera | 2024 | ✅ | "This plan will comply with federal mental health parity requirements." |
| Premera | 2025 | ✅ | "This plan complies with federal mental health parity requirements." |
| Molina | 2025 | ✅ | "Molina complies with the federal Mental Health Parity and Addiction Equity Act. Molina ensures that the financial requirements and treatment limitations on Mental Health Services or Substance Use Disorder..." |
| Kaiser | All years | ❌ | No parity language in any EOC |
| Regence | 2024 | ❌ | Not found in full policy documents |
Molina's 2025 EOC contains the most substantive parity compliance language — a dedicated section that goes beyond boilerplate. Premera's language is present but brief (one sentence per occurrence). Kaiser and Regence rely on implicit structural compliance with no explicit MHPAEA acknowledgment.
C4
Residential Treatment — PA and Coverage Summary
The most contested LOC tier — confirmed by verbatim extraction across all full-depth documents.
| Payer | Year | Covered | PA Required | Notes |
|---|---|---|---|---|
| Kaiser | 2023 | ✅ | ❌ | No PA for residential |
| Kaiser | 2024 | ✅ | ❌ | No PA for residential yet |
| Kaiser | 2025 | ✅ | ✅ | "All residential treatment" added to PA list |
| Molina | 2025 | ✅ | Unclear | Not explicit in sections examined |
| Premera | 2024 | ✅ | Unclear | PA forward-referenced, not listed inline |
| Premera | 2025 | ✅ | ✅ | "Admission to all residential treatment programs" |
| Regence | 2024 | ❌ | N/A | Residential not covered in any full policy |
05
Corpus Gaps
Regence 2025 full policy — only SBC summaries. Highest priority. Try
regence.com/go/2025/policy/WW/ patterns.Regence 2023 — archived. Recoverable via OIC SERFF or Wayback Machine.
Premera 2023 — archived, opaque doc IDs. Not publicly accessible.
Molina 2024 full EOC — only SBC summaries. 2024 cross-payer BH comparison incomplete without it.
Molina 2023 — only Silver SBC, no full EOC. Bronze and Gold tiers missing.
UHC (Charter) — individual exchange plans excluded. Behind SBC search tool at uhc.com.
06
Analysis Pipeline
scripts/download.py →
scripts/extract.py →
scripts/analyze_bh.py →
scripts/analyze_bh_claude.py
Raw PDFs in
raw/ · Extracted text in extracted/ · Analysis in analysis/
| Output File | Contents | Records |
|---|---|---|
bh_coverage_by_plan.json | Per-plan BH coverage profiles with 11 boolean flags | 63 |
raw_insights.json | Corpus-wide flag rate statistics | — |
cross_payer_comparison.json | Payer × flag matrix by year | — |
drift_analysis.json | YOY flag changes (all 10 doc-type artifacts) | 46 comparisons |
bh_definitions_registry.json | Verbatim med nec + LOC excerpts | 7 med nec · 44 LOC |
bh_deep_extraction.json | Claude API structured extraction with verbatim quotes | 36 |