Know Your Rights: I Have Individual Health Insurance
All individual health
plans are required to cover mental health and substance use disorder services,
including behavioral health services. This is because individual 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 (drug
and alcohol or mental health) services. 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 individual health insurance plans in Pennsylvania
- 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, 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.
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 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 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:
- 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?
- 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, visit the Pennsylvania Insurance Department’s Consumer Services Bureau
their hotline at 1-877-881-6388.