When it comes to the medical side of health insurance, it is safe to say we have all experienced frustration – whether it be figuring out what’s covered, cost, or trying to figure out what all the fine print means. Some things make it worse. If you or someone you love has a mental and/or substance use disorder, and are seeking coverage and find yourself in this frustrating position, you are in the same group as millions of others.
Ultimately, mental and/or substance use disorders affect our society in several ways that are not just limited to the direct cost of care. Without a policy allowing for effective treatment, people with these health conditions may not be as able, as others, to obtain education and/or training opportunities, which makes it difficult to find or maintain a job. In addition, people with these conditions may also require more social support services, and insurance coverage may not allow such support.
Don’t give up just yet. The Mental Health Parity and Addiction Equity Act (MHPAEA) might be the answer for you. That’s right – there is actually a federal law that aims to put insurance coverage of mental health care on equal level with physical health care.
What is the MHPAEA?
The primary goal of the MHPAEA is simple: to make it easy for all Americans to receive the care they need by prohibiting discriminatory practices by insurance companies that could limit behavioral health treatment.
In essence, mental health parity is the equal treatment of mental health conditions, as well as substance use disorders, when it comes to insurance plans. As such, when an insurance plan has parity, it means that if the plan provides unlimited doctor visits for a certain chronic condition, such as diabetes or similar, then it must also offer unlimited visits for a mental health condition, such as depression, and for substance abuse.
How does it Work?
On the surface, this sounds perfect for millions of people. However, you have to learn more about how the MHPAEA will work before you know how to move forward.
Although MHPAEA was initially passed by Congress in 2008, in November 2013, the government provided additional rules to implement the law. It is important to note that the conditions include factors such as the kind of health plan a person is enrolled in and even its size.
With the MHPAEA in place, many insurance policies will have to cover mental health and substance use disorders in the same manner as traditional medical and surgical treatment. This will apply to the following areas:
- Out of pocket maximums, coinsurance, and copays
- Care management tools
- Limitations on services, such as the number of inpatient days that are covered by the policy
- Coverage for seeking care from an out-of-network provider
Benefits and Services
Is the help I need covered by my insurance? This is one of the most frustrating questions faced by those with mental and/or substance abuse disorders. Really, any of us likely end up scratching our heads wondering what the point of insurance is if nothing needed is even covered.
Well, if an insurance plan has to follow federal parity law, then a few of the services that must be covered equally when it comes to treatment limits and payment amounts are: inpatient in-network and out-of-network, outpatient in-network and out-of-network, intensive outpatient services, partial hospitalization, residential treatment, emergency care and more.
With all this in mind, it is important to note that the MHPAEA is not a full umbrella of coverage for each and every case. Note the following:
- Insurance plans are not required to provide coverage for specific treatment
- Insurance plans are not required to provide coverage for mental illnesses or substance use disorders in general
With these points taken into consideration, insurance policies that do offer mental and substance abuse treatment must be provided at the same level as medical health conditions.
Also take into account individual state’s parity laws, as they aren’t all equal. If a state has a stronger state parity law, then health insurance plans regulated in that state must follow those laws. Basically, if state law requires plans to cover mental health conditions, then they must do so. In states with weaker parity laws, the federal law steps in to ensure the state at least meets the federal requirement of equal coverage. (A little check and balance on the state and federal level).
Does all this sound confusing?
If so, take the time to contact your health insurance provider to discuss what your policy offers. Along with this, you can always contact a rehab facility that can verify your insurance and answer any questions about your coverage as it relates to the treatment you are seeking.
Learn more about the Federal Parity Laws at https://beta.samhsa.gov/health-reform/parity