Mental health parity is a critical but often misunderstood concept in healthcare. The term refers to the requirement that insurance benefits for mental health and substance use conditions must be equal to those for other types of healthcare. This means that if your insurance plan provides unlimited doctor visits for a chronic condition like diabetes, it must also offer unlimited visits for a mental health condition such as depression or schizophrenia.
What is Mental Health Parity?
Mental health parity laws ensure that health insurance plans do not impose more restrictive limitations on mental health and substance use disorder benefits than on medical and surgical benefits. These laws are designed to provide fair access to treatment for mental health issues, which have historically been marginalized compared to physical health conditions.
Key Coverage Areas
To comply with mental health parity, health plans must cover the following areas equally for both mental health and physical health services:
- Inpatient care: Both in-network and out-of-network.
- Outpatient care: Both in-network and out-of-network.
- Intensive outpatient services.
- Partial hospitalization.
- Residential treatment.
- Emergency care.
- Prescription drugs.
Additionally, parity must be maintained in:
- Co-pays.
- Deductibles.
- Maximum out-of-pocket limits.
- Geographic location.
- Type of healthcare facility.
- Provider reimbursement rates.
- Clinical criteria used to approve or deny care.
Does Your Plan Have to Follow Parity?
Most health insurance plans are required to comply with federal parity laws. This includes:
- Group health plans for employers with 51 or more employees.
- Most group health plans for employers with 50 or fewer employees.
- Federal Employees Health Benefits Program.
- Medicaid Managed Care (MCOs).
- State Children’s Health Insurance Programs (S-CHIP).
- Some state and local government employee health plans.
- Any health plans purchased through the Health Insurance Marketplaces.
- Most individual and group health plans purchased outside the Health Insurance Marketplaces.
However, some plans are exempt, such as:
- Individual and group health plans created and purchased before March 23, 2010.
- Employer-sponsored plans that received an exemption based on the increase of costs related to parity.
- Some state and local government employee health plans.
If you are unsure about whether your plan follows parity, it is recommended to ask your insurance carrier, agent, plan administrator, or human resources department.
Recognizing Parity Violations
It is crucial to be aware of signs that your health plan may be violating parity requirements. Some common indicators include:
- Higher costs or fewer visits for mental health services compared to other kinds of healthcare.
- The need to get permission (pre-authorization) for mental health care but not for other types of healthcare.
- Denial of mental health services because they are not considered "medically necessary," with no clear criteria provided for this decision.
- Difficulty finding in-network mental health providers who are accepting new patients.
- Lack of coverage for residential mental health or substance use treatment or intensive outpatient care while providing coverage for other health conditions.
Steps to Take if Your Plan Violates Parity
If you suspect your health plan is not complying with parity laws, you have the right to file an appeal. Here are the steps you can take:
- Speak with your mental health professional or provider about the issue.
- Request an expedited appeal if it is an emergency, with the help of a mental health professional.
- Confirm with your insurance company that your services will be covered during the appeal process.
- Request written notification of the reason for denial. You should receive this within 30 days.
- Use template letters for the appeal, such as those provided by organizations like NAMI.
- Meet all deadlines in the review and appeal process to ensure your case is heard.
Conclusion
Mental health parity is a vital aspect of ensuring fair and equal access to mental health care. Understanding your rights and the requirements of your health plan can help you advocate for the care you need. If you face obstacles, resources like NAMI and other mental health organizations are available to assist you in navigating the appeals process and ensuring that you receive the coverage you deserve.
