Know Your Rights

Coverage Requirements

The Federal Parity Law does NOT require that insurers offer mental health or addiction coverage. Instead it requires that if an insurer offers ANY mental health or addiction benefits, the coverage must be equal to medical/surgical benefits.

To enforce this, benefits are placed into six areas for comparison purposes:

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

If a health plan has mental health or addiction benefits in ANY of the six areas, it must offer benefits in ALL of the areas where medical or surgical benefits are offered.

Limits on Visits, Days, or Copayments

In order to make sure benefits are equal for mental health and addiction medical/surgical, there are specific regulations that address how plans can limit your access to treatment. Examples of these limits are familiar to us all:

• Limit on the number of visits you can make in one year
• Limit on the number of days you can stay in the hospital
• Amount of your copayment each time you visit your provider
• Amount of money you pay for each service (testing, prescriptions, etc.)

The law does NOT ALLOW limits for your mental health or addiction treatment benefits that are separate from your medical or surgical treatment. It also does NOT ALLOW any limits on mental health/addiction treatment that are more restrictive than for medical/surgical treatment.

The exact regulatory language which defines the standard for determining any violations in this area is, “Any quantifiable treatment limitation must be no more restrictive than the predominant requirement or limitation that is applied to substantially all medical/surgical benefits.”

Other Limits on Treatment

Plans often have other ways they may limit access to care that aren’t as simple as limits on visits or co-payments. How a plan determines if your treatment was medically necessary; if this review is done before, during, or after treatment; the amount of money the plan pays its network providers for specific services; and the number of providers on its in-network panels are examples of these other types of limits.

The Federal Parity Law addresses these complicated limits by requiring that they be comparable to the medical/surgical limits and no more strictly applied to mental health/addiction benefits.

The exact regulatory language is, “Any nonquantifiable treatment limitation must be comparable and no more stringently applied for mental health/addiction than for medical/surgical benefits.”

Feel you have been unfairly treated by your insurance company? Take Action

Appeal and Disclosure Rights

The Federal Parity Law also grants consumers and providers rights not related to limits on treatment. These rights require that insurers provide you with certain information when treatment is denied or coverage changes are made.

• Insurers must disclose the criteria used for medically necessary determinations to consumers and providers upon request and provide an explanation for how it is applied. This is important because many treatment denials are based on this determination.
• Insurers must provide the reason for any denial of treatment in writing and free of charge. The insurer must send this upon denial but also upon request by a provider or consumer.
• If a plan decides to no longer offer mental health or addiction benefits, they must notify members immediately.

Feel you have been unfairly treated by your insurance company? Take Action

State and federal parity laws aim to create fairness in insurance coverage for mental health and addiction treatment by requiring that coverage is equal to physical health coverage. The federal and state laws provide different levels of protection and different rights. For plans that are covered by both laws, any stronger protections in Maryland Law supersede the Federal Law.

In order to fully understand your rights, it is important to know what type of insurance plan you have. Not all plans are covered by parity laws and some plans are covered by only the state or only the federal law. Read more about your Insurance Plan.