The information in this blog is courtesy of our partners at the Division of Financial Regulation.
Health benefits are physical health, mental health, and substance use disorder services paid for by your health insurer. Generally, the Mental Health Parity and Addiction Equity Act requires health plans to apply similar rules to mental health and substance use disorder benefits as they do for medical/surgical benefits, also known as physical health benefits.
Most health plans are required by law to offer parity for mental health or substance use disorder benefits. Generally, these plans include most employer-sponsored group health plans and individual health insurance coverage, including coverage sold through HealthCare.gov.
What parity means to you
Parity means that financial requirements, such as co-payments, and treatment limits, such as how many visits your insurance will pay for, must be comparable for physical health and mental health and substance use disorder services. Parity also applies to rules related to how mental health and substance use disorder treatment is accessed and under what conditions treatment is covered (such as whether you need permission from your health plan before starting treatment).
Here are some examples of common limits placed on physical and mental health and substance use disorder benefits and services that are subject to parity:
- Co-payments (also known as co-pays)
- Deductibles
- Yearly visit limits
- Need for prior authorization
- Proof of medical necessity
Although benefits may differ across plans, parity requires that the processes related to plan benefit determinations be comparable.
Parity protections
Here are examples of how the protections from this law may benefit you:
- Plans must apply comparable co-pays for mental health and substance use disorder care and physical health care.
- There can be no limit on the number of visits for outpatient mental health and substance use disorder care, if there is no visit limit for outpatient physical health care.
- Prior authorization requirements for mental health and substance use disorder services must be comparable to or less restrictive than those for physical health services.
Your right to information
Your health plan must provide information about the mental health and substance use disorder benefits it offers. You have the right to request this information from your health plan. This includes criteria the plan uses to decide if a service or treatment is medically necessary. If your plan denies payment for mental health and substance use disorder services, your plan must give you a written explanation of the reason for the denial and must provide more information upon request.
Appeal a claim denial
If your health plan denies a claim, you have the right to appeal the denied claim. This means you can ask your health plan to look again at its decision, and perhaps reverse the decision and pay the claim. Call your health plan to ask how to submit a request to appeal a claim.
You can find out more about the appeal process on the Appeals and external review page.
Find more information
Call your health plan administrator or human resources representative for the summary plan description and the summary of benefits and coverage. You can usually find this number online or on the back of your health insurance card. You may also be able to check your health plan benefits online to see what mental health and substance use disorder services are covered. See if they are comparable to the benefits for physical health.
If you have any questions or concerns about your mental health coverage, contact an insurance consumer advocate at 888-877-4894 (toll-free).
Questions or complaints?
File a complaint online or contact the Division of Financial Regulation:
Consumer hotline
888-877-4894 (toll-free)
Insurance
Email: DFR.InsuranceHelp@oregon.gov