Mental health parity, as provided by law, is designed to ensure that the mental health and substance use disorder benefits you are entitled to are covered just as your medical/surgical benefits, without restrictions or barriers to receiving benefits that are not covered by your medical/surgical benefits. This guide:
- Clarify whether your health plan must provide equal treatment and comply with the following regulations;
- Explain the protections provided by the law;
- Point out “red flags” that need attention;
- Explain how to understand your own mental health and substance use disorder benefits; and
- Explains what to do if you are denied coverage for mental health and substance use disorder benefits.
What is mental health parity?
Mental health parity is a legal requirement that group health plans and group health insurance organizations provide mental health benefits in a similar format to medical/surgical benefits.
Mental health parity does not require health plans to include every service under the mental health benefit, but if a health plan already offers mental health benefits, their coverage must be on par with other medical/surgical benefits (equal).
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The Mental Health Parity and Addiction Equity Act ( MHPAEA ) is a federal law that requires parity between covered mental health benefits, including substance use disorder benefits, and medical or surgical benefits. For example, a health plan should provide the same rights and benefit levels to a person with depression, an eating disorder, or drug addiction as the plan provides to a person with a medical condition, such as diabetes or heart disease.
Does Mental Health Equality Apply to Me?
It depends on the type of plan you are covered under. Mental health equal protection applies to people covered under:
- Employment-related group health plans, which are either “insured” (purchase coverage from an insurer on the group insurance marketplace) or “self-funded” (the plan pays claims with its own funds) and provide medical/surgical benefits and mental health benefits;
- Individual and small group employer health plans (2 to 50 employees) purchased through the Health Insurance Marketplace;
- some Medicaid programs, including Medicaid managed care plans; or
- Children’s Health Insurance Program ( CHIP ).
Under the Affordable Care Act, most group health plans are required to offer essential health benefits. This includes benefits for mental health and substance use disorder services.
Mental health parity does not apply to people covered by the following plans:
- Exclusive plans for retirees;
- Health insurance plans;
- Church-sponsored programs; and
- Certain small employer plans.
How can mental health equality help me?
If your plan provides both medical/surgical and mental health benefits, the following conditions must be treated the same:
- Financial regulations, such as copayments, deductibles, coinsurance, or out-of-pocket maximums;
- Treatment restrictions, such as limits on the number of visits per year or lifetime; and
- Other restrictions on the duration and scope of treatment.
Financial and treatment restrictions
Different categories of health benefits. The six categories of coverage under the mental health parity rules are:
- Hospitalization, in-network;
- Outpatient, in-network;
- Hospitalization, out-of-network;
- Outpatient, out-of-network;
- Emergency care; and
- Prescription medication.
| Mental Health Benefits | Medical/Surgical Benefits |
|---|---|
| Hospitalization: Drug Detoxification | Hospitalization: Appendectomy |
| Outpatient clinic: Psychologist consultation | Outpatient: Primary care visit for cold/flu symptoms |
| Emergency Care: Emergency Room Treatment for Overdose | Emergency Care: Emergency Room Treatment for Heart Attacks |
| Prescription drugs: Antidepressants | Prescription drugs: Blood pressure medications |
Under parity rules, every category must offer mental health and substance use disorder benefits when offering medical/surgical benefits. Benefits in the same category cannot have different financial provisions or treatment restrictions.
For example, if a health plan charges a $50 copay to see an in-network psychiatrist and a $25 copay for a visit with an in-network primary care provider, this could violate mental health parity because both providers are in the same category (outpatient, in-network). The financial rules that apply to mental health benefits are not comparable to those that apply to medical/surgical benefits.
Other treatment restrictions
When a plan imposes a nonquantitative treatment limit ( NQTL ) on a benefit, the limit is generally not expressed in a number (such as the number of covered visits or the amount of copayments collected), but it still limits the scope or duration of the treatment benefit. The NQTL for mental health benefits must be comparable to the NQTL for medical/surgical benefits and is more lenient in its application .
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Some examples of NQTLs include:
- Criteria for determining whether treatment or services are medically necessary or appropriate;
- requiring health plan approval prior to care;
- a list of covered prescription drugs;
- stepwise therapy or fail-first policies (i.e. the steps one needs to go through before getting a certain treatment);
- Coverage exclusions based on failure to complete a course of treatment; and
- Insurance restrictions based on geographic location, facility type, provider specialty.
For example, a participant is diagnosed with depression and high blood pressure. Under their plan, prior authorization is required each time the participant’s psychiatrist prescribes antidepressants. However, prior authorization is not required when the participant’s primary care provider prescribes blood pressure medication. This violates mental health parity.
These are some red flags that a health plan’s restrictions may violate mental health parity regulations :
- The health plan requires prior authorization or hospitalization monitoring for all mental health benefits (for example, benefits are approved for only a few days at a time and then prior authorization must be obtained again.)
- The plan’s network of mental health treatment providers is far less complete than its network of medical providers, making it more difficult or impossible for you to find a provider who will treat you at in-network prices.
- The plan requires prior authorization every three months for prescribing medications to treat mental health conditions.
- The plan refuses to cover mental health treatment because you did not complete your last treatment or because there is no “likely improvement.”
- Your health plan must be updated and submitted every 6 months or it will not be covered.
How can I learn about my plan’s mental health benefits?
You have the right to receive certain information about your health plan. This information can help you understand the mental health benefits you are entitled to and whether your plan complies with mental health parity regulations.
Five steps to understand your mental health benefits:
- Review your plan’s Summary of Plan Description and/or Summary of Benefits and Coverage.
- The Summary of Benefits and Coverage is usually available on your health plan’s website. If you do not have these documents, contact your plan provider to request them.
- If these documents do not have all the information you need, you can write to your health plan and ask for the rules for getting benefits.
- Ask your health plan if it requires any prior authorization or medical necessity for mental health benefits.
- If so, you should also ask how the standards for these mental health benefit limits compare to the standards for medical/surgical benefits.
- Request a copy of all the information about your health plan that states copays, annual limits, lifetime limits, medical necessity, and prior authorizations.
- The health plan must give you a copy within 30 days of your request.
- You can use this Department of Labor form template to request this information.
- Call your health plan’s customer service number directly (located on the back of your health plan card and on your plan’s Summary of Plan Description and/or Summary of Benefits and Coverage) and ask for more information.
- Always remember that you have the right to receive information about your welfare.
What can I do if I think a health plan has wrongly denied mental health benefits?
Let’s say you received mental health benefits from a healthcare provider and submitted a claim to your health plan, but the health plan denied payment. If you believe the plan wrongly denied you mental health benefits, take these three steps:
- Call your health plan. Have the following information ready:
- bills for denied mental health services;
- Explanation of Benefits ( EOB ); and
- A summary of your health plan’s plan description and/or summary of benefits and coverage.
- File an internal appeal with your plan.
- Call your health plan and ask what information/documentation is required for an internal appeal, and review the appeals process in the plan’s plan description summary.
- Appeals should be submitted in writing.
- Generally, you have 180 days to file an appeal, starting from the date the plan makes its decision on your claim.
- Usually, you must get an answer from the health plan within 60 days of filing your appeal.
- For most plans, if your health plan still refuses to pay your mental health claim after you have completed all internal appeals procedures, you can request an outside review.
- Your final internal appeal decision should include information on how to request an external review.
- You must request an outside review within 4 months of receiving the final denial from your health plan.
- The external reviewer must either overturn or agree with the rejection within 45 days.
Keep in mind that just because mental health benefits are denied does not always mean that the health plan violated mental health parity. The following denials may not violate parity:
- The service was not deemed medically necessary.
- The service is no longer appropriate in a particular medical setting or level of care. For example, hospitalization is no longer medically necessary based on current symptoms, so your health plan only pays for the outpatient visit.
- This service is considered experimental or research.
- This service is not a benefit under your health plan.