NYAPRS Note: The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Department of Labor (DOL) have produced the attached and following new resource to inform individuals about their rights under the Mental Health Parity and Addictions Equity Act (MHPAEA) and that provides examples of common limits that are placed on mental health and substance use disorder benefits and services that are now subject to parity, educates consumers about how to find information about their health plan benefits and coverage, as well as their right to appeal a claim if denied. Download the flyer and share!
Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits
There is now a law that protects your mental health and substance use disorder benefits. Read more about these protections here.
Mental Health Parity and Addiction Equity Act of 2008
Health benefits are physical health, mental health, and substance use disorder services paid for by health plans, often called “health insurance.” Generally, the Mental Health Parity and Addiction Equity Act (MHPAEA or “parity”) requires most health plans to apply similar rules to mental health and substance use disorder (MH/SUD) benefits as they do for medical/surgical benefits –referred to here as “physical health” benefits.
Health Plans and Parity
Most health plans are required by law to offer parity for MH/SUD benefits. Generally, these plans include most employer-sponsored group health plans and individual health insurance coverage, including coverage sold in the Health Insurance Marketplaces.
What Parity Means to You
Parity means that financial requirements, such as copayments, and treatment limits, such as how many visits your insurance will pay for, must be comparable for physical health and MH/SUD services. Parity also applies to rules related to how MH/SUD treatment is accessed and under what conditions treatment is covered (such as whether you need permission from your health plan before starting treatment).
Here are some examples of common limits placed on physical and MH/SUD benefits and services that are subject to parity:
? Copayments (or simply copays)
? Yearly visit limits
? Need for prior authorization
? Proof of medical necessity
Although benefits may differ across plans, parity requires that the processes related to plan benefit determinations be comparable.
Here are examples of how the protections from this law may benefit you:
? Plans must apply comparable copays for MH/SUD care and physical health care.
? There can be no limit on the number of visits for outpatient MH/SUD care, if there is no visit limit for outpatient physical health care.
? Prior authorization requirements for MH/SUD services must be comparable to or less restrictive than those for physical health services.
Ways to Find Out More
Call your health plan administrator or Human Resources (HR) rep for the “summary plan description” and the “summary of benefits and coverage.” You can usually find this number online or on the back of your health insurance card. You may also be able to check your health plan benefits online to see what MH/SUD services are covered. See if they are comparable to the benefits for physical health.
Your Right to Information
With respect to parity, your health plan must provide information about the MH/SUD benefits it offers. You have the right to request this information from your health plan.
This includes criteria the plan uses to decide if a service or treatment is medically necessary. If your plan denies payment for MH/SUD services, your plan must give you a written explanation of the reason for the denial and must provide more information upon request.
Your Right to Appeal a Claim
If your health plan denies a claim, you have the right to appeal the denied claim. This means you can ask your health plan to look again at its decision, and perhaps reverse the decision and pay the claim. Call your health plan to ask how to submit a request to appeal a claim.
For more about the Federal parity law, go to the Department of Labor (DOL) Mental Health Parity page or call toll-free at 1-866-444-3272 to speak to a DOL benefits advisor.
For assistance with parity issues from your state’s Department of Insurance, contact information can be found on the National Association of Insurance Commissioners website.
For additional resources go to Substance Abuse and Mental Health Services Administration (SAMHSA) page and the Centers for Medicare & Medicaid Services (CMS) page.