There are federal and state laws that protect your right to mental health and substance use treatment. These parity laws require that insurance companies provide equal coverage for mental health or substance use services as they do for physical health services.
According to parity laws, if your health plan covers mental health or substance use services, those services must not have different limits, costs, or approval processes than medical treatment. It should not be more difficult or expensive to get life-saving mental health or substance use care – like for depression or addiction – than it is for a necessary physical treatment – like for cancer or diabetes.
The federal parity law is called the Mental Health Parity and Addiction Equity Act (MHPAEA). Colorado also has its own parity laws that apply to private insurance, Health First Colorado (Medicaid) and the Children’s Health Insurance Program (CHIP). The Federal Affordable Care Act (ACA) also added parity requirements for small employer and individual market health plans. Parity does not require that all health insurance plans cover mental health and substance use treatment. In addition, parity does not apply to Medicare, and some self-funded state and local government plans.
Parity laws are only effective if they are enforced. It is important to take the time to understand both your rights and current insurance coverage.
Determine if services fulfill parity rules and regulations:
|What is in your health plan||Things to pay attention to||What to consider|
|Financial requirements||Deductibles, co-pays, and out-of-pocket limits; annual or lifetime limits on mental health or substance use care||Insurers are not allowed to require higher deductibles or charge higher co-pays for mental health or substance use services than for general medical services.|
|Treatment/service limitations||Number of visits or hospital days||The number of visits or hospital days for mental health or substance use care should be generally equivalent to those for physical health care.|
|Out-of-network benefits||Mental health or substance use providers outside of your network||If a plan offers out-of-network benefits for physical health care, then there must be out-of-network benefits for mental health and substance use care.|
|Prior authorization||Requirements for an insurer to review and approve mental health and substance use services to determine medical necessity||If you are not required to gain insurer approval before accessing specialty physical health care, you should not have the same requirements for mental health and substance use care.|
|Medical necessity requirements||Denials for treatment based on medical necessity||Medical necessity criteria should not be any more stringent for mental health and substance use than for physical health.|
|“Fail first” medication requirements||Requirements to try medications other than the preferred medication from your mental health or substance use provider||Insurers cannot treat mental health or substance use medications differently than other medications under their plans, including “fail first” requirements.|
|Provider networks||Availability of providers||There should be an adequate number of mental health and substance use providers in your network.|
Table adapted and used with permission from the Hogg Foundation for Mental Health, The University of Texas. “Mental Health Parity: Know Your Rights”.
If you think that your parity rights have been violated, there are several steps you can take. You can:
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