Know Your Plan

Individuals who have a fully insured plan offered by a large employer (51 or more employees) have the most parity protections in law. These plans are covered by both the Federal Parity Law and Maryland’s Parity Law (1993) and must meet the requirements of both laws. These plans MUST provide mental health and addiction benefits, and they must be equal to medical and surgical benefits.

Federal Parity Law requires:

Any Mental Health/Addiction Benefits offered must be equal to medical/surgical benefits in 6 categories:

1. In-network, inpatient
2. In-network, outpatient
3. Out-of-network, inpatient
4. Out-of-network, outpatient
5. Emergency services
6. Prescription drugs

Maryland Parity Law requires that plan benefits include:

• At least the same number of days for mental health and addiction inpatient care is covered under the plan for medical/surgical inpatient care
• At least 60 days for partial hospitalization
• Coverage for outpatient mental health/addiction visits must be equal to medical/surgical visit coverage, including diagnostic testing

Both Federal and Maryland Parity Laws require that plan benefits include:

• No discrimination in cost-sharing.
• No separate deductible, lifetime limit or annual out-of-pocket limits

Complaints Should be Filed With: Maryland Insurance Administration and/or US Department of Labor.

Learn More about your Rights under these laws.
Take Action and file a complaint or Contact Us to get help.

Individuals who have a self insured plan offered by a large employer (51 or more) are covered only by the Federal Parity Law. State laws cannot regulate self-insured plans. There is no requirement that these plans provide mental health or addiction benefits, but if they do, they must meet federal parity standards.

Federal Parity Law requires:

Any Mental Health/Addiction Benefits offered must be equal to medical/surgical benefits in 6 categories:

1. In-network, inpatient
2. In-network, outpatient
3. Out-of-network, inpatient
4. Out-of-network, outpatient
5. Emergency services
6. Prescription drugs

• No discrimination in cost-sharing.
• No separate deductible, lifetime limit or annual out-of-pocket limits.

Complaints Should be Filed With: US Department of Labor

Learn More about your Rights under these laws.
Take Action and file a complaint or Contact Us to get help.

No parity law applies to plans offered by a small employer. These plans are exempted from both Federal and Maryland Parity Laws. Fortunately, Maryland Insurance Law requires that all small employers who offer health insurance to their employees provide at least the Maryland Comprehensive State Health Benefit Plan, which does offer some behavioral health benefits.

Maryland Comprehensive Standard Benefit Plan includes:

• Detoxification in a hospital or related setting
• Inpatient and residential services up to 60 days in a hospital, licensed program, or residential crisis services.
• Two days of partial hospitalization may be substituted for one inpatient day
• Unlimited outpatient visits
• In-network cost-sharing for each service: 70% insurer/30% patient
• Out-of-network cost-sharing for each service: 50% insurer/50% patient

Complaints Should be Filed With: Contact Us to get help.

The Maryland Parity Law applies to individual and self-employed plans. Federal Parity Law does not apply until the 2014 implementation of the Affordable Care Act. In Maryland, these plans must provide some level of mental health and addiction coverage, and they must meet Maryland parity requirements.

The Maryland Parity law requires:

• No discrimination in cost-sharing for inpatient treatment or outpatient medical management
• No separate deductible, lifetime, or annual out-of-pocket limits.
• At least the same number of days for mental health/addiction inpatient care that are covered for medical/surgical inpatient care
• At least 60 days for partial hospitalization
• Insurance Coverage of Outpatient Visits
  80% for first 5 visits in a calendar year
  65% for the 6th through 30th visit in a calendar year
  50% for the 31st and subsequent visits in a calendar year

Complaints Should be Filed With: Maryland Insurance Administration

Learn More about your Rights under these laws.
Take Action and file a complaint or Contact Us to get help.

Federal Government Plans are covered by the Federal Parity Law, but Department of Defense and Veterans (TriCare) plans are exempt. State laws cannot regulate these plans.

Federal Parity Law requires:
Any Mental Health/Addiction Benefits offered must be equal to medical/surgical benefits in 6 categories:

1. In-network, inpatient
2. In-network, outpatient
3. Out-of-network, inpatient
4. Out-of-network, outpatient
5. Emergency services
6. Prescription drugs

• No discrimination in cost-sharing.
• No separate deductible, lifetime limit or annual out-of-pocket limits.

The Federal Employee Health Benefit Plan has had parity since 2001 due to President Clinton’s Executive Order signed in 1999.

Complaints Should be Filed With: US Office of Personnel Management

Learn More about your Rights under these laws.
Take Action and file a complaint or Contact Us to get help.

State and local government plans are covered under Federal Parity Law only, but these plans may request an exemption from the Federal Parity Law. Approved exemptions can be found at http://www.cms.gov/SelfFundedNonFedGovPlans/

Federal Parity Law requires:
Any Mental Health/Addiction Benefits offered must be equal to medical/surgical benefits in 6 categories:

1. In-network, inpatient
2. In-network, outpatient
3. Out-of-network, inpatient
4. Out-of-network, outpatient
5. Emergency services
6. Prescription drugs

• No discrimination in cost-sharing.
• No separate deductible, lifetime limit or annual out-of-pocket limits.

Complaints Should be Filed With: US Department of Labor or US Department of Health and Human Services

Learn More about your Rights under these laws.
Take Action and file a complaint or Contact Us to get help.

Medicare

Medicare is specifically exempted from the Federal Parity Law, and state laws cannot regulate Medicare. Fortunately, the 2008 Medicare Improvement for Patients and Providers Act (MIPPA) created some equality in outpatient behavioral health treatment for Medicare patients.

Prior to 2008, Medicare paid only 50% of the cost of outpatient behavioral health services but 80% of covered outpatient medical services. By 2014, Medicare will pay 80% of outpatient behavioral health services. The outpatient parity coverage will phase-in through 2014 as follows:

• January 2011: Medicare will pay 55% of covered charges
• January 2012: Medicare will pay 60% of covered charges
• January 2013: Medicare will pay 65% of covered charges
• January 2014: Medicare will pay 80% of covered charges

Two types of visits won’t have to wait for the phase-in and are currently paid at 80%:

• Brief office visits for monitoring or changing prescriptions
• Evaluations and tests that are used to diagnose or confirm mental health diagnosis

Currently, Medicare has a 190 day lifetime limit for inpatient mental health care. This same limit does not exist for inpatient medical or surgical care. There is pending federal legislation to address this issue, but it has yet to be enacted.

The Centers for Medicare and Medicaid Services publication, Medicare and Your Mental Health Benefits, may provide more information about covered benefits and cost-sharing.

Medicaid

Only Medicaid managed care organizations that provide medical AND behavioral health coverage are regulated by the Federal Parity Law. The federal government has not released the federal parity regulations specific to the Medicaid program. We will update this section of the website as more information becomes available. For detailed information about parity in addiction treatment in Medicaid, download the Substance Use Provider Toolkit.