Know Your Rights: My Large Employer Provides My Health Insurance
Health insurance provided by a large employer (51 or more
employees) that is fully insured is called large group insurance. Pennsylvania
law requires large group insurance to cover certain serious mental illnesses as
well as minimum levels of benefits for alcohol and substance use treatment, as
explained in more detail below. Many large group policies provide additional
and more comprehensive benefits for mental health and substance use disorder
treatment, but they are not required to do so. Check with your insurance
provider or your human resources department to learn more about what benefits
are covered by your health insurance plan.
The minimum required benefits for alcohol and substance use
treatment are listed here, but your insurance plan may be required to cover
more than these minimum benefits, as we will explain next. (The insurance company may use medical
management techniques, like prior authorization or medical necessity reviews,
above these minimum benefit levels.) The
minimum benefits are:
- 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.
Whether your insurance company only covers these required
benefits or additional mental health and substance use disorder benefits, your health insurance plan 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 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, called the parity law. It can be difficult to
know if your health insurance company is following this law, so look for these
- 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”?
As one specific example, we talked earlier about the minimum
benefits for alcohol and substance use treatment required by Pennsylvania law.
Your insurance company can only use the minimum limits we listed above if they
use the same limits for equivalent physical health services. If their limits
for alcohol and substance use treatment are lower, the insurance company likely
would be violating the parity law. If your insurance plan has more generous
benefits (such as no limits) on a given physical health service, they must
offer those same generous benefits for corresponding behavioral health and
substance use disorder services.
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.