Know Your Rights: My Employer Self-Insures
Check with your human resources department to determine what
benefits are covered by your health insurance plan. Self-insured employer plans
are not required to cover any specific mental health and substance use disorder
benefits, but many do provide these benefits. And, if they do provide mental
health and substance use disorder treatment benefits, they cannot impose less favorable benefit limitations on mental health
and substance use disorder benefits than on physical health benefits. This means your benefits must be the same in
- What you
pay: Co-pays, co-insurance, deductibles, and out-of-pocket maximums;
- How much
treatment you can get: Limitations on services utilization, such as limits
on the number of inpatient days or outpatient visits that are covered;
- The use of management tools, such as prior authorization requirements;
doctors you can see: coverage for out-of-network providers;
- The criteria and process used to determine what is considered medically necessary
This is because of a federal law called the Mental Health
Parity and Addiction Equity Act. It can be difficult to know if your employer
is following this law, so look for these red flags:
- Do you have a higher co-pay for a behavioral
health services than you do for physical health?
- Do you have limits on how many times you can see
a behavioral health provider, but you don’t have limits or have different
limits on how many times you can see a physical health provider?
- Do you have to ask your insurance company for
permission (called prior authorization) to access behavioral health services,
but you don’t for physical health services?
- May you see an out-of-network doctor for
physical services, but not behavioral health services?
- Does your insurance company say it will not pay
for behavioral health services your doctor says you need, but you don’t think
you would have that problem for physical health services?
- Does your insurance company make you try
outpatient behavioral health services before it will pay for inpatient
behavioral health care?
- Has your insurance company refused to pay for
substance use disorder treatment in a residential treatment facility because
they said it wasn’t “medically necessary”?
These aren’t the only warning signs for possible
violations of this law, but these are obvious red flags you can look for. If
you think your insurance company is making it more difficult for you to access
behavioral health services than physical health services in any way or have
questions about this requirement, contact the United States Department of
Labor’s Employee Benefits Security Administration (EBSA) for private sector
employer plans, or the Department of Health and Human Services, Centers for
Medicare and Medicaid Services for public sector employer plans. Self-insured
health insurance plans are solely regulated by one of these federal agencies,
and not by the Pennsylvania Insurance Department. Pennsylvanians can visit the EBSA website or contact the EBSA regional
office in Philadelphia at 1-215-861-5300, or contact the CMS office in
Baltimore, Maryland at 1-877-267-2323, extension 4-61565.