Understanding Your Coverage for Mental Health and Substance Use Disorders

Pennsylvania Department of Insurance logoThousands of Veterans in our commonwealth and their family members have a mental illness or substance use disorder. Individuals living with a mental illness or substance use disorder should not be discriminated against. Mental illness and substance use disorders should be covered the same as any other illness-like cancer or diabetes. And it’s the law.

DMVAInsurance companies and health plans that provide benefits for mental health and substance use disorders must ensure they are covered equivalently to the benefits for other medical conditions. This is because of a federal law called the Mental Health Parity and Addiction Equity Act (parity law). The following information is provided by the Pennsylvania Department of Military and Veterans Affairs and the Pennsylvania Insurance Department and is designed to help Veterans and their families better understand their health insurance regulations for mental health and substance use disorder treatment.

How do I know if the parity law applies to my plan?

The parity law applies to most employer plans, most individual coverage you buy directly from an insurance company – including a broker – or through Pennieā„¢ (the state’s marketplace), Medicaid (sometimes called Medical Assistance or Health Choices), and the Children’s Health Insurance Program (CHIP). If you get your coverage from your employer, you may have additional rights for alcohol and substance use treatment under a Pennsylvania law known as Act 106.

What does parity mean to me?

The parity law applies to your coverage in 3 main ways:

  1. The amount you owe for treatment, such as higher copays, deductibles, or coinsurance.
  2. Limits on how many times you can see your provider or how many days you can receive inpatient care.
  3. Additional steps you have to take or rules you have to follow to get your provider’s recommended care covered.

How can I tell if my plan is following the parity law?

If your plan makes it more expensive or harder for you to get mental health or substance use disorder care than it does for other medical conditions, your plan may be violating the parity law.

Here are some examples that may indicate parity law violations:

  • The copays, coinsurance or deductibles for mental health or substance use disorder services are higher than for other medical and physical health conditions (insurers may use the term medical/surgical benefits or M/S).
  • You have to get approval (prior authorization) before receiving most mental health or substance use disorder services but usually don’t have to get approval for most other medical services.
  • You have to try to treat your condition with an outpatient program before your plan will cover care in a hospital or residential treatment facility for mental health or substance use disorders.
  • Your therapist recommends you meet, for example, twice a week for your condition but your plan will only cover one visit per week or stops covering visits in the middle of the year.
  • Your mental health or substance use disorder provider has to give information to your plan showing the recommended treatment is “medically necessary” but that requirement rarely applies to your other medical provider’s recommended care.
  • You have to wait longer or travel further to see a mental health or substance use disorder provider in your plan’s network than you do for other medical providers.

What can I do if I think my plan isn’t following the parity law?

There are steps you can take if you think your plan isn’t covering mental health or substance use disorder services equivalently to other medical services.

You have the right to get information from your plan

The parity law requires plans to give you the criteria they use to decide if a service or treatment is medically necessary. If your plan denies payment for mental health or substance use disorder services, your plan must give you a written explanation of the reason for the denial.

You have the right to appeal your plan’s denial

If your health care provider says you need a certain health care service but your insurance company or health plan disagrees or doesn’t pay, you have the right to appeal that decision and have it reviewed by an independent medical expert. The following consumer guide may include helpful information: Consumer Guide

You may choose to submit a complaint to the Insurance Department

Upon receiving a complaint, the Insurance Department’s Consumer Services team will take appropriate steps to help resolve it if warranted by the facts of the complaint. The Insurance Department may also direct you to a more appropriate government agency depending on the type of your health care coverage.

While we recognize that a significant number of veterans may be privately insured, please be advised that even while TRICARE is exempt from the parity law, Department of Defense regulations require mental health and substance use disorder coverage under TRICARE to be in parity with medical/surgical coverage.

To connect with your veteran community, please visit PAVET Connect.

After reading the information provided here, if you still have questions about the parity law and how it applies to you, or to file a complaint, please visit the Pennsylvania Insurance Department’s Consumer Services Bureau or call the hotline at 1-877-881-6388.