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​Individual Health Insurance Parity

If you or your family member bought your health insurance directly from an insurance company or on Pennie, PA's health insurance marketplace, you have what is called individual health insurance.

 

Coverage Requirements

All individual health plans are required to cover mental health and substance use disorder services, including behavioral health services. Pennsylvania sets a 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 individual 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

Individual health insurance plans must also cover certain types of drugs. Some of the categories of drugs insurance companies must cover include anti-depressants, mood stabilizers, and medication-assisted treatment for substance use disorders. However, insurance companies do not have to cover every drug in each of these categories.

Reasonable Limits

Your insurance company can still put reasonable limits on these 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 days or outpatient visits that are covered
    • The use of management tools, such as prior authorization requirements
    • Which doctors you can see, and coverage for out-of-network providers
    • The criteria and process the insurance company uses to determine what is considered medically necessary treatment.

Red Flags

It can be difficult to know if your health insurance company is following this law, so if you feel they may not be, look for these red flags:

    • A higher co-pay for behavioral health services than you have for physical health services
    • Limits on how many times you can see a behavioral health provider, but no limits or different limits on how many times you can see a physical health provider
    • A requirement to ask your insurance company for permission (called prior authorization) to access behavioral health services, but not for physical health services
    • Seeing an out-of-network doctor for physical services, but not behavioral health services
    • Your insurance company says it will not pay for behavioral health services your doctor says you need
    • Your insurance company making you try outpatient behavioral health services before it will pay for inpatient behavioral health care
    • Your insurance company refuses 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. 

Get Help

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 file a complaint using our Pennsylvania Consumer Services Online Portal (CSO).

If you have questions about parity, visit the Pennsylvania Insurance Department's Consumer Services Bureau online or call their hotline at 1-877-881-6388.