Know Your Rights
Fair Insurance Coverage: It’s the Law
The federal Parity Law requires equitable coverage of substance use disorder and mental health benefits in both the public and private health insurance markets.
Plans covered by the federal Parity Law cannot apply more restrictive financial requirements or treatment limitations to behavioral health benefits compared to other medical or surgical benefits covered by the plan.
• Financial requirements include co-pays, deductibles, co-insurance, and other out-of-pocket costs.
• Treatment limitations include both quantitative (number or frequency of visits) and non-quantitative (medical management tools) limitations.
Representing a major step forward, the Mental Health Parity and Addiction Equity Act (the federal parity law) was passed in 2008 and requires most health insurance plans to cover mental health and addiction disorder benefits and physical health benefits equally.
• The federal Parity Law applies to most insurers, including:
• Large group health plans
• Plans in the individual and small group markets
• Medicaid managed care plans that offer coverage for MH and/or SUD benefits
• Coverage provided through the Children’s Health Insurance Program
• Medicaid Alternative Benefit Plans, including those provided to the Medicaid expansion population
While the concept of parity is simple, the federal parity law is complex and in the ten years since its passage there have been serious challenges to its full implementation and enforcement.
The struggle has now shifted from the legislative to the regulatory sphere and from the federal level to the states, where primary enforcement authority resides. Tennessee recently passed model parity legislation designed to strengthen enforcement efforts by encouraging greater transparency and accountability from insurers and state regulators.
Full implementation of the Parity Law would end discriminatory insurance coverage for those with mental health and substance use disorders. But that will only happen with increased vigorous enforcement of the law.
Know Your Rights: Parity for Mental Health and Addiction
Fair Insurance Coverage: It’s the Law
“Parity: Fairness in Health Coverage in Tennessee” trifold
What is Parity?
Parity is about making health plans treat individuals with behavioral health conditions fairly. Because of federal and state laws, most insured Americans are now entitled to receive mental health and addiction benefits on a comparable basis to benefits for other conditions.
Mental Health Parity and Addiction Equity Act (2008)
Does not require insurers to provide mental health or addiction benefits, but if they do, treatment limits and out-of-pocket costs must be at the same level as medical or surgical care.
Affordable Care Act (2010)
Strengthens coverage for mental health and addiction care by requiring insurers to provide behavioral health coverage by making it one of the ten Essential Health Benefits and by requiring almost all types of insurers to meet parity requirements. *Medicare, TRICARE and a few other plans are exempt from federal parity law. Visit www.tnparityproject.org for more details.
• Types of care: Hospital treatment · Residential treatment · Emergency/ Crisis Care · Prescription drugs · Both in-network and out-of-network
• Out-of-pocket costs for mental health or addiction care may not be greater than for other medical care.
• Treatment limits (visit or day limits) must be no more restrictive than for other medical care.
• Other limits must not be more restrictive than for other types of medical care
— prescription drug costs or requirements
— prior approval requirements
— clinical standards used to approve or deny care
Common Parity Violations
- Fewer visits or days covered for mental health or addiction care.
- Residential or partial hospital care not covered for mental health or addiction. Example: Addiction residential care is not covered, but a skilled nursing facility is covered for stroke
- Higher out-of-pocket costs for mental health or addiction care. Example: the copay for a mental health therapy visit is higher than copay for an endocrinologist for diabetes.
- Separate deductible for mental health or addiction care on top of the overall deductible. A deductible is the amount you are responsible for before the health plan begins to pay.
- More frequent denial for mental health or addiction care than for other medical care because the health plan determines that the care is not medically necessary.
- Prior approval required more often for mental health or addiction care than for medical care
- Step therapy: The least expensive mental health or addiction treatment is required before the prescribed care can be considered.
- In-network mental health or substance use providers not available and the health plan does not pay for the out of network providers in your local area.
Asserting Parity Rights
Right to Information
Health plans must provide information about mental health and addiction benefits it offers. Health plan members and their providers may request information that may show whether a plan is discriminating in its coverage.
Right to Appeal a Claim
If a health plan denies a claim, plan members have a right to appeal the denied claim. For information about how to contact a health plan/ insurance company and for pursuing an appeal visit: www.tnparityproject.org
TN Department of Commerce and Insurance
For fully insured plan, whether individual, through private employer or non-Federal government employer in TN, file parity complaint here: http://bit.ly/tninscomp.
You can also call the Insurance Division’s Counsumer Insurance Services at (800) 342-4029 or (615) 741-2218
Department of Labor/Employee Benefits Security Administration
The DOL/EBSA handles parity complaints involving self- insured prviate employer health plans. For assistance, call (866) 444-3272 or visit: www.askebsa.dol.gov for information.
Department of Health and Human Services/Centers for Medicare and Medicaid Services
HHS/CMS handles parity complaints involving state and local government employer plans that are self-insured. Complaints can be filed through the HHS parity complaint portal, by phone with the CMS Heath Insurance Helpline at 877-267-2323 x 6-1565
or by email to: firstname.lastname@example.org or NonFed@cms.hhs.gov
Contact your MCO or complaints can be filed with the Office of Civil Rights Compliance by phone at: (855) 857-1673 or (615) 507-6464 or by email to: HCFA.email@example.com
- NAMI Tennessee is a nonprofit grassroots education, support and advocacy organization with 20 local affiliates comprised of individuals with mental illness, family members and others in the mental health community. www.namitn.org Helpline: (800) 467-3589
- The Tennessee Association of Alcohol, Drug & other Addiction Services. The Tennessee REDLINE (1-800-889-9789) is a 24/7 toll- free information and addiction and mental health referral line.
- The TennCare Advocacy Program is an organization committed to helping Tennesseans get, use, and keep TennCare. www.tenncareadvocacy.com Phone: (800) 758-1638 TTY Users: (877) 779-3103
- The Department of Mental Health and Substance Abuse Services provides an array of prevention, early intervention, treatment, habilitation, and recovery support services for Tennesseans with mental illness and substance abuse issues. Helpline: (800) 560-5767
- Community Catalyst is a national non-profit advocacy organization working to build consumer and community leadership to transform the American health system. Substance use disorder website www.communitycatalyst.org•
- Department of Labor Website on Mental Health Parity www.dol.gov/ebsa/mentalhealthparity
- The Parity Implementation Coalition worked for passage of MHPAEA and continues to support and advance the Federal Parity Law’s full implementation and enforcement. parityispersonal.org
- The Kennedy Forum www.thekennedyforum.org
- Parity Track is a comprehensive resource for information about mental health and substance use disorder parity and federal and state parity laws. www.paritytrack.org
The Tennessee Parity Project is a coalition of behavioral health advocates, providers, and those with lived experience working to make sure that Tennesseans’ rights to non-discriminatory health insurance coverage under federal and state parity laws are protected. Launched by NAMI TN with support from The Healing Trust, the Project is dedicated to advocating for and educating Tennesseans of their rights to access mental health and addiction services.