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