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 detoxification);
  
• 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 (outpatient/partial hospitalization)
  
• 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 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;
  
• Which 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 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”?
  

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.