Know Your Plan

The different state and federal rules governing mental health coverage make understanding the insurance system difficult. Some plans are covered by federal law, some by state law, and some by neither. Understanding your plan coverage is vital to understanding your rights and being able to take appropriate action if you believe your rights have been violated.

Large Employer Fully Insured (51+ employees)

Individuals who have a 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:


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
  • 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 .
  • 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.

In a traditional fully insured health plan, your company pays a premium. The premium rates are fixed for a year, and you pay a monthly premium based on the number of employees enrolled in the plan. The insurance company pays all of the medical claims for the employees, therefore holds the risk.
These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
Consumer lives in the community and receives treatment up to seven days per week at treatment facility or outpatient center. This is sometimes referred to as intensive outpatient treatment.
Including but not limited to: copays, deductibles, and annual limits.
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Large Employer Self insured (51+ employees)

Individuals who have a 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:

  • 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.

A self-insured plan is when the employer holds the risk of paying for the employee’s health benefit claims. Normally an employer buys insurance and pays a monthly premium for your coverage (you may pay a portion of that monthly fee through payroll deduction). The insurance company pays all of the medical bills for insured employees. If employees have a large amount of medical bills that exceed the total of the monthly premiums collected by the insurance company, the insurer is “at risk” and pays the difference. Some large companies prefer to hold the risk themselves (self-insured) and contract with insurance companies to only administer their insurance plan (i.e. handling enrollment and paying health care providers for services rendered, with the company’s money).
These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
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Small Employer (2-50 employees)

These plans are covered by the Federal Parity Law as of 2014 implementation of the Affordable Care Act. These plans MUST provide mental health and addiction benefits, and they must be equal to medical and surgical benefits. Only a few plans that were sold prior to 2014 were grandfathered and do not have to comply with the federal parity law and may not be required to cover mental health nor addiction treatment. If you are unsure if you are in a grandfathered plan, you should check with your insurance carrier or human resource manager.

Federal Parity Law requires:

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

Federal Parity Law requires that plan benefits include:

  • No discrimination in .
  • No separate deductible, lifetime limit or annual out-of-pocket limits.
  • No discrimination in how benefits are managed including how medical necessity is determined.


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

.

These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
Including but not limited to: copays, deductibles, and annual limits.
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Individual or Self-Employed

These plans are covered by both the Federal Parity Law and Maryland’s Parity Law (1993) and must meet the requirements of both laws as of 2014 implementation of the Affordable Care Act. These plans MUST provide mental health and addiction benefits, and they must be equal to medical and surgical benefits. Only a few plans that were sold prior to 2014 were grandfathered and do not have to comply with the federal parity law and may not be required to cover mental health nor addiction treatment. If you are unsure if you are in a grandfathered plan, you should check with your insurance carrier or human resource manager.

Federal Parity Law requires:

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


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
  • 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 .
  • No separate deductible, lifetime limit or annual out-of-pocket limits.
  • No discrimination in how benefits are managed including how medical necessity is determined.

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.

These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
Consumer lives in the community and receives treatment up to seven days per week at treatment facility or outpatient center. This is sometimes referred to as intensive outpatient treatment.
Including but not limited to: copays, deductibles, and annual limits.
Print This Post Print This Post

Federal Government Plans

Federal Government Plans are covered by the Federal Parity Law.

Federal Parity Law requires:

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

  • 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.

These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
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State and Local Government Plans

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:

  • No discrimination in .
  • 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.

These include overnight or longer stays at a hospital or other facility that is part of your plan network.
These include visits to a mental health/addiction provider that is a member of your insurance plan.
These include overnight or longer stays at a hospital or other facility that isn’t part of your network.
These include visits to a provider who is not a member of your insurance plan.
These include visits and any treatment you receive in the emergency department at a hospital.
This includes coverage for medications prescribed by your provider. Insurance plans often create a preferred drug list, which includes generic medicines as the cheapest and most preferred type of prescription.
Including but not limited to: copays, deductibles, and annual limits.
Print This Post Print This Post

Medicare and Medicaid


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. As of 2014, Medicare will pay 80% of outpatient behavioral health services. The outpatient parity coverage was  slowly phased-in from 2011- 2014.

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

Medicaid is a joint federal and state program that provides medical insurance for residents who meet income eligibility requirements or other criteria. Maryland’s Medicaid program is operated through the Department of Health and Mental Hygiene.

In March 2016, the Centers for Medicare and Medicaid services released the final Medicaid parity regulations, which were in effect as of May 30, 2016. Essentially, anyone who receives ANY services from a managed care organization, including only medical/surgical care is protected by the federal parity law. In states like Maryland where the mental health and substance use disorder services are “carved out” or managed by an organization other than the managed care organization, the state agency is responsible for ensuring compliance with the federal parity law. Medicaid recipients only receive services via the fee-for-service system and are not enrolled in a managed care organization are not covered by the federal parity law.

For more information about the Medicaid final rule, you can download the Parity Implementation Coalition Fact Sheet.

Medicare is the insurance program provided by the federal government that covers all US citizens age 65 and over or those who meet special criteria.
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