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Archive of Past Tips of the Month

 

Getting mental health parity documents from your health plan or employer.

Under the Mental Health Parity and Addiction Equity Act (MHPAEA) any health plan or health insurer that applies a certain type of treatment limitation to medical/surgical benefits cannot apply that same type of treatment limitation to mental health or substance use disorder (MH/SUD) benefits unless the treatment limitation is applied in a comparable way and no more stringently.  For example, if a plan or insurer requires prior authorization or concurrent review for inpatient mental health treatment, then application of these requirements must be comparable to and no more stringent than the prior authorization or concurrent review requirements that are applied to inpatient medical/surgical treatment.

Sometimes you need to prove that a MH/SUD treatment limitation is applied more stringently than a medical/surgical treatment limitation.  The starting point is comparing the MH/SUD medical necessity criteria with the medical/surgical medical necessity criteria.  If you have your health coverage through work you can ask the health plan or the plan administrator for a copy of the plan’s medical necessity criteria.  MHPAEA says that the plan or the plan administrator has to give you the MH/SUD medical necessity criteria, but says nothing about the medical/surgical criteria.  This is where the federal ERISA law can help.  Under the ERISA general disclosure requirements you can ask the plan or plan administrator for all “instruments under which the plan is established or operated.”   That means documents such as all medical necessity criteria.  This includes medical necessity criteria for medical/surgical benefits.  The health plan or the plan administrator usually has to give you these documents within 30 days.  On October 23, the United States Department of Labor and other agencies issued an FAQ with more information about this.  It is available on their website at http://www.dol.gov/ebsa/faqs/faq-aca29.html.

 

June 2015

Q: Why are telehealth services a good option for getting mental health care?
A: Telehealth, including telemental health services, allow patients to get medical care from their health care provider even if they cannot get to the provider’s office.  By using technology patients can get services from a different location such as a clinic closer to their home or in some situations their own home.  A patient can be evaluated, participate in therapy, and be monitored by their doctor without having an in-person visit.  Telemental health services provide the following benefits:

  1. Increased access to mental health services for people who live in remote locations and may have never received mental health services.
  2. Decreased travel time and cost to the patient to get necessary treatment.
  3. Continuity of care or quality patient care on an on-going basis for the patient. 

Health insurance plans including private insurance plans, Medi-Cal, and state employment health plans cover telemental health services. 

Disclaimer: The Parity Tip of the Month program is for educational purposes only and does not constitute legal advice. If you have a legal question, please contact Disability Rights California or another attorney of your choice.

 

May 2015

Q: Can a health insurance plan apply a source-of-injury exclusion for a mental health condition if the injuries are the result of a medical condition?

A: No. A source-of-injury exclusion is a denial of coverage by an insurance plan for injuries sustained by a specific activity or cause that is written in the policy. An insurance plan cannot deny coverage for injuries sustained even if “intentionally self-inflicted” if they are due to the person’s medical condition such as depression. If a person required medical or surgical treatment due to an injury that was not self-inflicted then the insurance plan could not deny coverage for the same treatment that was the result of a self-inflicted injury.

 

To find out if your health insurance plan has any source-of-injury exclusions you should request a copy of your Evidence of Coverage (EOC) from your health insurance plan. The EOC provides a description of all the benefits and exclusions under your plan.

 

April 2015

Why does one of my medications have a higher copay than another?

Q. My health plan charges different co-pays for my medications depending on what “tier” my medication is on. What do they mean by “tiers” and are they allowed do that?
A. As discussed in previous tips, the federal law, the Mental Health Parity and Addiction Equity Act (MHPAEA), requires parity of benefits and services within each of their six classifications. Those classifications are defined as:

  • Inpatient, in-network
  • Inpatient, out-of-network
  • Outpatient, in-network
  • Outpatient, out-of-network
  • Emergency care
  • Prescription drugs

All benefits and services covered in a plan must be in one of these classifications. They do not allow the plans to leave anything out, nor are the plans allowed to create additional classifications. However the law does allow some flexibility within the classifications, and that is the subject of this tip.
Most, if not all, plans have different tiers or levels of cost sharing when it comes to prescription medications, network status of providers, and specialization of providers. There are specific restrictions placed on defining the tiers in each of these classifications.
Prescription drugs: if a plan applies different financial requirements for different tiers of prescription medications, the tiers must be based on reasonable factors, but not what the medication is generally prescribed for. The reasonable factors are defined as the processes, strategies, evidentiary standards, or other factors used to determine placement in the tiers. As an example, the tiers may be defined by the cost of the medication, if there are over-the-counter equivalents, and if there are generics available, among other factors. Medications used to treat mental health or substance use disorders cannot be subject to more scrutiny or more strict standards than the medications used to treat physical health conditions. Once the tiers are established, then each tier is evaluated for parity. The December 2014 Tip of the Month talks about financial parity and the February 2015 Tip of the Month discusses parity for nonquantitative treatment limitations.
Network standards of providers: Another area where tiering is common is the out of pocket costs based on the status a provider has in the provider network. Some plans limit this tiering to in-network and out-of-network while others will have more generous coverage for preferred providers than for participating providers, which is more generous than for out-of-network providers. Plans may divide their benefits based on this type of tiering as long as the tiers are defined by reasonable factors. Again, reasonable factors are those processes, strategies, evidentiary standards, or other factors used to define the tiers, without looking at the area of medicine practiced. Once these tiers are established, the plans must then make sure there is parity within each tier.
Outpatient status: Some health plans have also broken down outpatient services into several tiers and then each tier had a different financial requirement. MHPAEA has restricted the type of tiering allowed for outpatient services to two tiers: 1. Office visits, such as seeing your physician and 2. All other outpatient services, such as outpatient surgery, facility charges for day treatment centers, or laboratory services. Each plan must then provide parity within each of the tiers.
MHPAEA does not allow other subclassifications or tiering. If your plan has created other subclassifications, they are in violation and need to be reported to the appropriate regulating agency. 

 

March 2015

What Does Parity Mean, Part 2

Last month, we posted a tip about how the federal parity law, the Mental Health Parity and Addiction Equity Act (MHPAEA) evaluates parity for out-of-pocket costs. The differences can cost consumers tens of thousands of dollars every year. But financial requirements are only part of the parity puzzle. There are other restrictions and limitations that have no specific dollar amount but can prevent the consumer from receiving appropriate services as much as being unable to afford care.
These limits, called nonquantitative treatment limitations (NQTL), include items such as medical necessity definitions, standards for provider admission to the network, and fail-first policies i.e., policies that requires a consumer to try a lower-cost treatment and show the treatment is ineffective before a more expensive treatment is approved.

The federal law says that a group plan may not impose a NQTL to mental health or substance use disorder benefits in any classification unless that NQTL is imposed on medical/surgical benefits in that classification. The NQTL must be the same both on paper and in practice. This means that, in designing and applying the NQTLs, the plan may not use any processes, strategies, evidentiary standards or other factors that are more stringent for mental health and substance use disorder benefits than for medical/surgical benefits.

As an example, Plan A includes both visits to a person’s primary care doctor and individual therapy with a psychologist in their outpatient, in-network classification.  In the Evidence of Coverage, the plan allows 10 visits per year to the doctor for a single condition before needing prior authorization for further treatment of the same condition. If the plan normally approves, as a general practice, an additional 10 days of treatment for a physical condition, but only 2 additional days for a mental health condition, then the plan is in violation of MHPAEA. While the original number of visits is the same, and the prior authorization requirement is the same, the plan is more restrictive when it authorizes further care in practice. The plan must not discriminate in its actual, unwritten prior authorization procedures.  The plan must grant the same number of days during the prior authorization process for both medical and mental health conditions.

The confusion with the NQTLs is that there are situations in which an equal application of a limitation can lead to an unequal result. Let’s say a plan covers all medically necessary treatment for both medical/surgical care and mental health and substance use care. The evidentiary standard the plan uses for determining if a treatment is medically necessary is based on recommendations of a panel of experts. The experts for medical/surgical care have similar experiences and medical training as the experts for mental health and substance use disorders. Because the evidentiary standard is the same on paper and in practice, it is a valid restriction, even if it results in differences such as number of visits in a year or the number of days in a facility for medical/surgical care and mental health and substance use disorder care.

 

December 2014

Q. Mental health treatment and services are often not the same as physical and surgical treatment and services so how can you compare them? If the treatments or services are different how can you have “parity”?

A. The key is in providing mental health coverage that is “equal” to physical (medical and surgical) coverage both in financial requirements and in treatment limitations.  Mental health parity means that private health plans must provide mental health benefits in a way that is no more restrictive than the way they provide physical health services.
Because health plans must comply with both the state and federal parity laws, there are a lot of parts to this answer so it will be covered in these tips over the next few months. This tip looks at the money, or what it means to have equal out-of-pocket costs, as defined by the federal parity law.
The Mental Health Parity Addiction and Equity Act (MHPAEA) of 2008 provides specific guidelines to the state and federal regulatory agencies and the health plans. The law states that health plans may not apply any financial requirement to mental health or substance use disorder benefits in any classification that is more restrictive than the predominant financial requirement of that type applied to substantially all medical/surgical benefits in the same classification.   A financial requirement is what you are required to pay for a covered service, for example, a deductible, co-insurance (a percentage of the cost), or a copayment (a fixed dollar amount regardless of the cost).
The first thing to do is describe how the plans decide what their limitations and classifications are.
Each plan estimates what they expect to pay out for benefits for the coming year.  They look at how many services and benefits were used in the past couple of years and trends in treating different physical and mental health conditions. They use that information to assign benefits into different classifications, and to decide what kind of limitations will be in each classification, how much they will need to pay out, and how much the total plan will cost them. They also look at how much the consumer will share in the cost.
Next we need to define some of the terms in the law.
Classification: The plans must define each and every treatment they cover and put them into one of six classifications:

  1. inpatient, in-network;
  2. inpatient, out-of-network;
  3. outpatient, in-network;
  4. outpatient, out-of-network;
  5. emergency care; and
  6. prescription drugs.

Every time there is an evaluation for parity, the evaluation will be between benefits and services within the classification.  For example, inpatient, in-network mental health or substance use benefits will be compared with inpatient, in-network medical or surgical benefits, and so on.
Substantially All: In general, once the plans have assigned a benefit to a classification the plans must look at what financial requirement applies to the majority of the benefits within a classification. If there is a financial requirement that applies to at least 2/3 of all the benefits in that group, you continue with the analysis. If there is no single financial requirement that applies to at least 2/3 of the benefits in that classification, then the financial requirement cannot be applied to mental health benefits. As an example, let’s say that a plan requires a copay for the benefits within their inpatient, in-network class. The plan estimates that 20% of the time, there will be no copay charged. That means that 80% of the time, there will be some sort of copay. Because there is a requirement for some sort of copay for more than 2/3 of the services in the classification, it’s appropriate to charge a copay for mental health services in this classification.
Predominant: If the classification meets the 2/3 definition of substantially all, the next step is to decide what the dollar limit is on the financial requirement. The dollar limit that is used is the dollar limit of the predominant financial requirement. Predominant in this law just means that it applies to more than one half of the services.
Let’s go back to the example above. We know that there is going to be some sort of copay, but not sure what it is yet. If the plan estimates there will be a $15 copay 52.7% of the time, then the $15 copay is what applies to mental health claims.  The $15 copay is the predominant financial limit because it is the financial limit that applies more than 50% of the time.
But let’s say there is no one copay amount that applies more than half of the time. The chart below is an example.


Copayment amount

$10

$15

$20

$50

Percent subject to copay

25%

20%

37.5%

17.5%

Because none of the  copays are expected to be applied more than half of the time, the plans can add the percentages together, starting with the highest, until they get over half. When you add the two highest percentages in this chart, you find that the two highest copays are expected to be applied 55% of the time (37.5% for the $20 copay + 17.5% for the $50 copay). So the predominant copay is either $20 or $50. The law tells the plans that they can only apply the least restrictive, or lowest cost, of predominant group. So in this case, the lowest cost in the predominant group is $20. That is the copay that is applied to mental health services in this classification.
The next tip will look at how the federal parity law defines “equal” coverage when the limitation has no numeric value, such as utilization review or step therapy.


Mental Health Parity and Addiction Equity Act of 2008, 45 C.F.R. §§ 146.136 (2013).


November 2014

Traumatic Brain Injury

Q: I have recently sustained a traumatic brain injury and my doctor is recommending I get some mental health services. Will my health plan from work cover these expenses?

A: It will depend largely on the source of your insurance plan. Generally if your insurance plan was purchased in California by your employer, mental health services are regulated by a combination of the California Mental Health Parity Act (MHPA) and the Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). The MHPA has a list of 9 severe mental illness that insurance companies are required to cover. They are: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa. If your doctor has identified any of these diagnoses for you, then your insurance plan is required to cover all medically necessary mental health services needed. MHPAEA is then involved in determining if the benefits you receive are in parity with the medical/surgical care the plan provides. MHPAEA is focused on the costs and restrictions in receiving your benefits, ensuring that it isn’t any more difficult to receive your mental health benefits than it is to receive your medical/surgical benefits.

If your insurance plan is funded by your employer, also called a self-funded plan, then mental health services are covered under the federal Mental Health Parity and Addiction Equity Act (MHPAEA). Under MHPAEA, any professionally recognized mental health disability is covered, but only if the plan provides mental health benefits. The difference between the California law and the federal law is that California makes coverage mandatory, while the federal law does not. The federal law only requires that if a plan offers mental health benefits, it must be no more restrictive than medical/surgical benefits.

If your insurance is from a federal employer, through the Federal Employees Health Benefits Plan (FEHBP), your plan is exempt from the parity laws listed above. However, the FEHBP have parity requirements built into the plan. You will need to contact your health plan to find out what your coverage may be.

These groupings are pretty general and there are some variations that can make determining the source of your plan tricky. If you have questions, you should contact an attorney or either of the health plan regulating agencies, Department of Managed Health Care or Department of Insurance. Both agencies have help desks that can answer your questions.


October 2014

Q. I just started college and I’m looking for health insurance I can afford. I know the college offers a student health plan, but I don’t know what they cover. Do student health plans cover mental health services also?

A. Student health insurance coverage is a type of individual health insurance coverage. In California, the university either purchases a blanket policy that covers students and their dependents or provides a self-funded plan. Last month’s Tip of the Month discussed self-funded plans and the requirements for mental health coverage. If the student plan is self-funded, it would be subject to the same requirements. To read this discussion, the tip is located here under Archive of Past Tips of the Month: http://www.disabilityrightsca.org/CalMHSA/CalMHSAParity.html

Purchased health care plans must comply with both the Public Health Service Act and the Affordable Care Act, with a couple exceptions. This means that mental health services must still meet the requirements established in the Essential Health Benefits of the Affordable Care Act, and the plans cannot refuse to cover a student with prior medical conditions. Those exceptions, however, can make student health insurance different than other, employer-based or independently purchased plans.

The first difference, and maybe the most obvious, is that only students can receive student health insurance. The student must be registered at an institute of higher education like a college or university before they can receive services from that school’s health plan. The plan may offer the opportunity to cover the student’s dependents, but the student is the primary recipient of the coverage.

The second difference is there may be either a coordination of benefits policy provision or a nonduplication of benefits policy provision. This is for those students who have more than one health plan, like the parents’ health plan and the school’s health plan. The school’s health plan may require that the parents’ plan pay for coverage first, and if there are expenses left over, the student plan will cover them.

One further item to note is that the student administrative health fees assessed with your tuition are not a cost-sharing item like co-pays and co-insurance fees. Student administrative health fees are charged to all students enrolled at a college or university, regardless of whether a student enrolls in a student health plan or has a health plan from another source. The administrative health fees are used to support services and activities that foster a healthier campus community.

45 CFR Part 147

 

September 2014

Q: What is a self-funded employer plan and do those plans have to provide mental health parity also?

A: A self-insured group health plan (often called a self-funded plan) is a plan in which an employer or union pays for health coverage directly instead of paying premiums to a separate company for a health care plan or health insurance. It is standard procedure for the employer or union to set up a special trust fund to pay for claims under these self-funded plans. The trust fund holds both the funds set aside by the employer and the employee’s contributions. While any employer can choose to provide health care under this type of arrangement, self-funded plans are most commonly set up by larger companies, unions, and nonfederal governmental agencies.

For parity purposes, self-funded plans offered by private entities are not subject to state insurance laws. Instead, they fall under the federal Employee Retirement Income Security Act of 1974 (ERISA). The federal Mental Health Parity and Addiction Equity Act (MHPAEA) amended ERISA to require a plan that offers any mental health or substance use benefits to provide these benefits at parity with the plan’s medical and surgical benefits. These self-funded plans are regulated by the U.S. Department of Labor, whom you should contact if you believe your plan violates parity requirements.

Nonfederal government agencies, such as state or local governments, with self-funded plans, fall under the Public Health Service (PHS) Act, also modified by MHPAEA, with the same parity requirements. If an employee has a problem receiving mental health or substance use disorder benefits from the plan, the agency that established the plan is also the agency that would handle any complaints. Sponsors of self-funded, nonfederal government plans can opt out of several provisions of the PHS Act, including mental health parity. Employees should receive a notice if the employer has opted out, but they can also contact their benefits administrator if they are unsure.

Sometimes, it is hard to tell if a plan is a self-funded plan or a plan purchased through a separate entity.  This is because self-funded plans are typically administered by a third-party administrator, which is usually a commercial health plan such as Blue Cross, UnitedHealthcare, Health Net, etc.  You can find out from your employer’s or union’s (if you have coverage through your union) benefits administrator whether or not the plan is self-funded.

 

August 2014

Q. Are my child’s mental health needs covered by the California Mental Health Parity Act also?

A. For health care plans and insurance plans regulated by the state of California, mental health insurance coverage for children under the age of 18 with a severe emotional disturbance (SED) are covered by the California Mental Health Parity Act. The Act defines a child with SED as a child under the age of 18 who 1) has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms, and 2) who meets the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and Institutions Code.

The criteria for Welfare and Institutions Code Section 5600.3(a)(2) are:

  1. Due to the mental disorder, the child has a substantial impairment in at least two of the following areas: self-care, school functioning, family relationships, or ability to function in the community and either of the following occur:
      • The child is at risk of being removed from the home or has been removed from the home
    • The mental disorder and impairments have been present for at least 6 months or are likely to continue for over a year without treatment.
  2. The child displays one of the following: psychotic features, risk of suicide or risk of violence due to a mental disorder.
  3. The child meets special education eligibility requirements under Chapter 26.5 (commencing with Section 7570) of Division 7 of Title 1 of the Government Code.

What does this all mean? Imagine a 14 year old child with depression. He is sleeping most of the time and hasn’t been eating much or showering at all. When he is at school, he is unable to focus and is not participating in class. He’s been declining for the last 6 months and has attempted suicide twice, with the last attempt leading to hospitalization. Under the California parity law, the insurance company must cover any medically necessary treatment equal to the terms and conditions of the medical/surgical benefits. He can receive a variety of services including, but not limited to, community based services such as Therapeutic Behavioral Services and wrap services, and residential services.

 

June 2014

Q. I’ve seen articles about the federal parity law and I’m confused about the nonquantitative treatment limitations. What are they?

A.  There are two ways that an insurance plan can limit the amount of coverage a person has. One limit is a quantitative limit. A quantitative limit will have something to do with a number, such as co-payments, co-insurance, number of visits in a year, etc. The other limit is nonquantitative. Nonquantitative treatment limitations (NQTL) do not have a number associated with them. NQTLs include, but are not limited to, medical management, step therapy and pre-authorization. Under the federal parity law, a group health plan or coverage cannot impose a NQTL on a mental health or substance use disorder benefit unless there is one on the medical surgical benefit in the same classification.

To determine whether a NQTL is being applied inappropriately, you need to look at the terms of the plan (or coverage) as it is written and as it is being applied. A plan cannot apply any methods that limit treatment any more stringently for mental health or substance use disorder benefits than it does for medical or surgical benefits.

For more information about mental health parity, see our parity webpage at http://www.disabilityrightsca.org/CalMHSA/CalMHSAParity.html.

 

May 2014

Q: My health plan denied my appeal for mental health services, what should I do?

A: You are entitled to a second level of appeal, which is called an external review or independent medical review.  You must determine who regulates your health plan and file an appeal with that agency.  For example, your plan may be regulated by California Department of Managed Health Care, California Department of Insurance or U.S. Department of Labor.  The information about which agency regulates your plan can be found in the plan’s Evidence of Coverage and also should be included in the denial notice sent by your health plan.  The Evidence of Coverage should include instructions about how to file with the appropriate agency.  Your Evidence of Coverage can usually be found online or you can call your plan and request a copy be sent to you.

Once you determine who regulates your health plan you can file an appeal with that agency.  A doctor that is not part of your health plan will review the appeal.  It is important to include medical records and letters of support from your treating doctor that explains why the service you want to be covered is medically necessary, as well as a copy of the denial from your health plan.  This additional evidence will be reviewed by the independent medical reviewer.  You can usually submit the appeal online, by mail or fax.

April 2014

Q: Why is your health plan’s Evidence of Coverage (EOC) an important document?

A: The Evidence of Coverage (EOC) is important because it is a summary of your health care services plan. State regulations require that at a minimum the EOC include but is not limited to the following:

  1. A description of all the benefits, exclusions, exceptions, reductions, co-payments, and deductibles under the plan.
  2. The procedures to follow if there is a dispute between you and your health care services plan including any requirement for arbitration.
  3. A description of your health care service plan’s grievance policy including the address and telephone number for you to contact if you would like to make a complaint.

The EOC likely has medical and legal words that may be difficult to understand.  You could contact your health plan for clarification.  You may also consult with an attorney.  In the event you misplace your EOC or would like to request a copy you should contact your health care services plan.  For the exact terms and conditions of your coverage refer to your health care services plan contract.  (28 CCR §1300.63.1). 

 

March 2014

Q: Do mental health parity laws apply to my Medi-Cal Managed Care Plan?

A: Yes, mental health parity laws do apply.  Effective January 1, 2014, Medi-Cal beneficiaries will receive certain mental health benefits through their Medi-Cal Managed Care Plans.  These benefits include individual and group mental health evaluation and treatment, psychological testing, outpatient services for monitoring medication treatment, outpatient laboratory, medications, supplies and supplements, psychiatric consultation and screening and brief intervention.  Specialty mental health services will still be provided by County Mental Health Plans.  Examples include intensive day treatment, inpatient psychiatric services, day rehab and crisis intervention.  The transition and coordination of mental health benefits to Medi-Cal Managed Care Plans must meet equal coverage requirements under the law.  Access to appropriate doctors and medications, prior authorization requirements, treatment limitations and number of visits must be equal for mental and physical conditions.  The California Department of Managed Health Care (DMHC) oversees the Medi-Cal Managed Care Plans.  If you think that your Managed Care Plan wrongfully restricted or denied mental health care services, you can submit a complaint to DMHC at 1-888-466-2219 or online at https://wpso.dmhc.ca.gov/ContactForm/ .

 

February 2014

Q: Can I continue to receive mental health treatment while my appeal is pending with the health plan?

A: Yes.  The health plan administrator or insurance issuers must notify you at a time sufficiently in advance of the reduction or termination of the benefit, to allow you enough time to appeal and obtain a determination before the benefit is reduced or terminated.  A patient receiving ongoing care will be faced with a disruption and potential harm and should therefore be afforded an adequate opportunity to appeal the termination or reduction of already granted benefits before it takes effect.

Additionally, a notice to a patient about an adverse benefit determination must include certain information to ensure they understand how and why the decision was reached, as well as provide information their appeal rights.  A notice must include the following information:
-        Specify the reason or reasons for the adverse determination;
-        Reference the specific plan provisions on which the determination is based;
-        Provide a description of any additional material or information necessary for the patient to make their claim and explain why that information is necessary;
-        Provide a description of the plan’s review procedures and the time limits;
-        Include information about the right to appeal and bring a civil action following an adverse benefit determination; and 
-        If claim involves urgent care, include a description of the expedited review process.

If it is a group health plan or a plan providing disability benefits, the plan must also:
-        Disclose an internal rule, guideline or protocol that was relied upon in making the adverse determination and
-        If the adverse determination is based on medical necessity or experimental treatment, the plan must provide an explanation of the determination, applying the terms of the plans to the patient’s medical situation.

 

January 2014

 

What is Mental Health Parity

Q: I’ve been hearing a lot in the news about mental health parity. What is it and how will it affect me?

A: There are two major mental health parity laws that affect people in California. The first was passed by the Federal government and has been the subject of a lot of news lately.

The Federal law, known as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires that, if a group health plan is going to offer mental health or substance use disorder benefits, then those benefits cannot be more restrictive than the physical health benefits. This means that if the insurance company is going to require copayments for doctor visits, or wants to limit the number of visits to a specialist, then they must have the same or similar requirements for both mental health and physical health.

MHPAEA also affects restrictions that cannot be measured or counted. These are called nonquantitative treatment limitations. They include requiring prior authorizations before receiving treatment, or setting standards for adding providers to the company’s network. The law requires insurance companies to use the same methods when setting up these limits for mental health benefits and physical health benefits.

Previously, MHPAEA was only for large group plans, but the Affordable Care Act has added MHPAEA to the small employer and individual markets.

The Department of Labor, the Department of Health and Human Services, and the Treasury created several FAQs to answer questions about the MHPAEA. You can access those FAQs at http://www.dol.gov/ebsa/faqs/main.html or http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html.

The California Mental Health Parity law is a little different. It requires a plan to provide the same or equal benefits for mental health conditions that it covers for other medical conditions. However, the California law is limited to severe mental illnesses. They are: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorders, panic disorder, obsessive-compulsive disorder, pervasive developmental disorder or autism, anorexia nervosa, bulimia nervosa. The law also protects children with serious emotional disturbances.

Insurance companies are required to apply the same terms and conditions to mental health and physical health benefits. The conditions are things like copayments, deductibles, and maximum lifetime benefits. An example would be that your plan sets an amount as copay for physician’s appointments. That copay amount must be the same as the copay amount you pay to see your therapist.

The Department of Managed Health Care has a webpage that describes the Mental Health Parity law and provides answers to some of the most common questions. You can access their webpage at http://www.dmhc.ca.gov/dmhc_consumer/br/br_mentalhlth.aspx.

What all of this means is that if you need mental health care, and your insurance company has limited what you can receive, there are laws to protect you.  If you think the insurance company has wrongfully restricted or denied mental health care services, you should seek the advice of an attorney who may be able to help you.

 

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