Know Your Rights

A Consumer Guide to Private Health Insurance Coverage for Mental Health and Substance Use Disorder Treatment in the Commonwealth of Pennsylvania

Introduction

Treatment for mental health and substance use disorders, also known as drug and alcohol issues, is essential to the health and wellbeing of Pennsylvanians. And, insurance coverage for mental health and substance use disorder benefits is critical to ensuring consumers can access and afford these services. In many cases, the laws and regulations governing insurance companies require certain services to be covered in certain ways. In order to ensure Pennsylvanians understand what benefits they are guaranteed access to, the Pennsylvania Insurance Department has put together this consumer guide to health insurance coverage for mental health and substance use disorder treatment in the Commonwealth. 

The First Step: Know Your Insurance

Before you begin reading about what benefits you are entitled to, you need to understand what kind of health insurance coverage you have. The laws and regulations that govern insurance coverage can be complicated, and impact different types of insurance coverage in different ways. To make sure you get the right information, let’s start here:

Do you get health care coverage through a government program, through an employer, or did you or a family member buy insurance directly from an insurance company?

• If you get your insurance from a government program, such as Medicare, Medicaid (sometimes called Medical Assistance or Health Choices in Pennsylvania), or the Children’s Health Insurance Program (CHIP), you should check with the program from which you receive coverage to understand what benefits you are entitled to. Detailed information on these programs is not contained in this guide, but contact information for Medicare, Medicaid and CHIP can be found in the “Who can you call if you need assistance?” section.
  
• If you or your family member bought your health insurance directly from an insurance company or on the federal health insurance marketplace, Healthcare.gov, you have what is called individual health insurance. Read the section titled “Know Your Rights: I Have Individual Health Insurance.”
  
• If you get your health insurance through your employer, we have a few more questions:
• Does your employer self-insure? Sometimes employers purchase coverage from a health insurance company for a set premium and the health insurance company pays all of the claims for health care services. This is called being fully insured. However, in many other cases, your employer will use a third part to administer their health insurance, but pay claims for health care services themselves. This is referred to as being self-funded or self-insured. It can be difficult to tell if your employer self-insures or is fully insured, because many of the third parties hired by self-insured employers are also health insurance companies that offer fully insured coverage. If you are not sure if your employer self-insures or is fully insured, contact your human resources department, benefits manager, or the person in management that handles insurance and they can tell you. If you know your employer self-insures, visit the section titled, “Know Your Rights: My Employer Self-Insures.” If your employer is fully insured, we have two last questions.
• Is your employer based in Pennsylvania? Fully insured employer plans are monitored by the state in which the employer is based. So, if you live in Pennsylvania, but work for an employer based in another state, you should contact that state’s insurance department. If you live in another state, but your employer is based in Pennsylvania, the information in this guide applies to you.
• How many employees work for your employer? If your employer has 50 or fewer employees, they are considered a small employer. If your employer has 51 or more employees, they are considered a large employer. If you work for a small employer, visit the section titled, “Know Your Rights: My Small Employer Provides My Health Insurance.” If you work for a large employer, visit the section titled, “Know Your Rights: My Large Employer Provides My Health Insurance.”

Most people get insurance in one of these ways. If you do not believe you fit into any of these categories or are not sure which category you fall in, call the Pennsylvania Insurance Department at 1-877-881-6388 and we can help you figure out which type of health insurance you have.