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Know Your Rights: My Small Employer Provides My Health Insurance

Health insurance provided by a small employer (50 or fewer employees) that is fully insured is called small group insurance. Most small group health plans are required to cover mental health and substance use disorder services, including behavioral health services. This is because all non-grandfathered small group 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 services (mental health and drug and alcohol treatment). 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 small group health insurance plans in Pennsylvania must cover:

  • 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, small group health insurance plans must also cover certain types of drugs. Some of the categories of drugs small group health insurance plans have to cover include anti-depressants, mood stabilizers, and drug treatments for opioid dependence. Small group health insurance plans, however, do not have to cover every possible drug in each of these categories.

In addition to the federal law requirement to cover the Essential Health Benefits, Pennsylvania law also requires small group plans to cover minimum levels of benefits for alcohol and substance use treatment. The minimum required benefits for alcohol and substance use treatment are listed here:

  • 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.

As a result of the federal law requirement to cover the Essential Health Benefits, the benefits identified above must be covered without the day, admission, or session limits identified above, though above these benefit levels they may be subject to medical management like prior authorization or medical necessity review.

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 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 or 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, 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”?

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.