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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 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: coverage for out-of-network providers;
  • The criteria and process used 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 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.