Know Your Rights: My Small Employer Provides My Health Insurance
Health insurance provided by a small employer (50 or fewer
employees) that is fully insured is called small group insurance. Most small group health plans are required
to cover mental health and substance use disorder services, including
behavioral health services. This is because all non-grandfathered small
group health insurance plans are required to cover certain benefits called Essential Health Benefits. Essential
Health Benefits include certain categories of services, one of which is mental
health and substance use disorder services, including behavioral health
services (mental health and drug and alcohol treatment). Pennsylvania gets to
choose a “benchmark” set of benefits that defines the minimum amount of
services that must be covered within each of these categories. For example, for
plans that begin on or after January 1, 2017, all small group health insurance
plans in Pennsylvania must cover:
- Mental/Behavioral Health Outpatient Services
- Mental/Behavioral Health Inpatient Services
- Substance Use Disorder Outpatient Services
- Substance Use Disorder Inpatient Services
Because of the Essential Health Benefits, small group health insurance plans must
also cover certain types of drugs. Some of the categories of drugs small
group health insurance plans have to cover include anti-depressants, mood stabilizers,
and drug treatments for opioid dependence. Small group health insurance plans,
however, do not have to cover every possible drug in each of these categories.
In addition to the federal law requirement to cover the
Essential Health Benefits, Pennsylvania law also requires small group plans to
cover minimum levels of benefits for alcohol and substance use treatment. The
minimum required benefits for alcohol and substance use treatment are listed
- Up to seven days of detoxification per
admission; four admissions per lifetime (hospital or non-hospital inpatient
- 30 days of non-hospital residential treatment
per year; 90 days per lifetime);
- 30 sessions of outpatient/partial
hospitalization services per year; 120 sessions per lifetime
- Family counseling and intervention services;
- 30 additional outpatient/partial hospitalization
sessions, which may be exchanged on a two-to-one basis to provide 15 additional
non-hospital, residential treatment days, are also available.
As a result of the federal law requirement to cover the
Essential Health Benefits, the benefits identified above must be covered
without the day, admission, or session limits identified above, though above
these benefit levels they may be subject to medical management like prior
authorization or medical necessity review.
Your insurance company can still put reasonable limits on
Essential Health Benefits, such as only covering services performed by an
in-network provider or only covering services if they are medically necessary,
but it is critical to know that your
health insurance company 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 terms of:
- 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 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 or process the insurance company
uses to determine what is considered
medically necessary treatment.
This is because of a federal law called the Mental Health
Parity and Addiction Equity Act. It can be difficult to know if your health
insurance company is following this law, so look for these red flags:
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, visit the Pennsylvania Insurance Department’s
Consumer Services Bureau
or call their hotline at 1-877-881-6388.
- 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”?