Why do you need to know about mental health parity? Because it is a law that was fully implemented in 2014 that directly affects just about everyone who has health insurance, but only 4% of Americans surveyed were aware of it. Read more to learn about how mental health parity pertains to you and the people you care about.
A Little Background
In 2008, Congress passed an act to ensure equal health insurance coverage of treatment for mental illness and addiction with other types of health conditions. The official name of the act is the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA). It is usually referred to simply as the Mental Health Parity Act. While the law was passed in 2008, health insurance companies were given time to implement the changes that the law required. Before the law, mental health treatment was usually covered at lower levels than physical health treatment. Number of visits per calendar year could be limited and preauthorization was often required before you could receive mental health care. Consumers may have had to pay more money out of pocket. Insurance companies had greater leeway to deny claims for mental health treatment without providing you with an explanation. In 2014, health insurance companies were required to give full parity for mental health and substance abuse treatment for the majority of plans. (Read this article to learn about plans that do not have to follow federal parity).
What is Parity?
A health insurance plan is said to have parity when its members are given the same access to mental health care as they are given for physical health care. So if you get unlimited physician office visits, you will also get unlimited office visits for outpatient mental health. If you pay a $20 copay to visit most physicians, you will pay the same amount to visit your psychologist. If your deductible is waived when you see your primary care physician, it is also waived when you see your substance abuse counselor. If you can get an appointment with a local physician within two weeks, you are supposed to be able to get an appointment with a local psychiatrist within two weeks.
Advocating for Yourself
Mental health parity is great news! We have the right to receive the same coverage for treatment of mental health and substance abuse problems as we do for physical problems. Yay! End of story, right? — Unfortunately no. Health insurance is big business for some companies that are run for profit, which means that they may be more focused on their bottom line than they are on your health care. To for-profit companies, mental health parity is bad news because it means that they stand to lose money . . . unless they find ways to minimize the damage such as passing the extra costs on to their consumers (you), reducing reimbursement rates for providers and/or limiting use of mental health benefits by deeming them not “medically necessary.” So where does that leave you?
Understand Your Benefits. Be sure that you thoroughly read and understand your plan benefits summary which will tell you exactly what your coverage is for all aspects of your heath care. You may have received this summary in the mail, by email or you can access it online through your insurance company website. I know it’s difficult to understand health-insurance-speak, which is why I wrote a post that explains the common health care terminology. Before seeking treatment, you will want to know what your deductible is (if you have one), whether or not it applies to the type of treatment you are seeking, and the amount you will have to pay to the provider at the time of services (your copay or coinsurance). You will also want to know if you have the option of seeing an out of network provider and what your coverage is for out of network services. If you didn’t understand the last two sentences, I encourage you to read this post!
Watch for Red Flags. According to the National Alliance of Mental Illness (NAMI), here are some signs that your insurance company may be violating mental health parity [my comments in italics]:
- Higher costs or fewer visits for mental health services than for other kinds of health care. [While your insurance company may be required to provide unlimited visits for mental health treatment to achieve parity, they may try to limit your treatment by claiming that it is not “medically necessary.” They may also attempt to steer you toward lower cost alternatives by favoring treatment with medications rather than psychotherapy, by asking you to see a primary care physician rather than a psychiatrist, or by limiting access to providers who receive greater reimbursements due to higher levels of education and training.]
- Having to call and receive permission to get mental health care covered [referred to as pre-authorization], but not being required to do this for other types of health care.
- Getting denied mental health services because they were not considered “medically necessary,” but the plan does not answer a request for the medical necessity criteria they use. [Mental health parity requires health insurance companies to provide an explanation when they deny coverage.]
- Inability to find any in-network mental health providers who are taking new patients, but you can for other health care. [This may indicate that your insurance company is not contracting with a sufficient number of providers to meet the demand of its members, and/or that providers are unwilling to contract with the company due to low reimbursement rates and poor provider relations.]
- The plan will not cover residential mental health or substance use treatment, or intensive outpatient care, but they do for other health conditions. [Also beware of efforts by your insurance company to shorten the duration of your treatment in residential, partial hospitalization or intensive outpatient programs by claiming lack of medical necessity.]
Contact a Representative. If you suspect that your insurance company is not providing mental health parity, you can contact a customer relations representative to ask for an explanation or to file a complaint. There is a general phone number on the back of your insurance card that you can call and contact information for specific departments is also available on the company website. If you receive your health insurance through your employer, you can contact human resources and ask for the designated benefits representative. In addition, your state may have resources for advocacy or filing complaints against health insurance companies who are not in compliance with mental health parity. Here is the link to information from the Oregon Insurance Division.
Choose Non-Profit. If you are purchasing your own health insurance or otherwise have the freedom to choose which company to work with, you may want to consider a non-profit. Regardless of your personal opinions on this hot-button topic, it is logical that a health insurance company that is not driven by profits will be more likely to prioritize the care of its members. In addition, the non-profit companies tend to have better relationships with providers because they generally reimburse at higher rates and do not tend to limit how patients are treated to cut costs. If more providers are willing to contract with your insurance company, you will have greater access to the best care for yourself and your loved ones.
The time of year is nearing when you may be eligible to choose your employer sponsored benefits or to purchase health insurance through the federal or state exchanges. Don’t let another year go by where you make an uninformed decision and end up with a plan that doesn’t meet your needs. Become an informed consumer by educating yourself and accessing your resources. Make informed choices about your health care. Know when and how to advocate for yourself to ensure that you receive the mental health parity that is afforded to you by the law.
[DISCLAIMER: I strongly encourage you to verify your benefits with your insurance company before seeking health care or making important decisions about your plan. I am not a health insurance benefits specialist, nor a representative of your insurance company.]
Resources
Does Your Insurance Cover Mental Health Services? – APA
Understanding Psychotherapy and How it Works – APA
What is Mental Health Parity? – NAMI
MentalHealth.gov
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