The Pennsylvania Insurance Department recently issued a reminder to state residents about the rights and benefits they are entitled to as part of the state’s mental health and substance use disorder parity law.
The state’s Health Insurance Coverage Parity and Nondiscrimination Act aligns with the federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), mandating that health insurers provide equitable access to mental health and substance use disorder services included in their plans.
The law make certain that insurers do not impose more restrictive requirements on these services compared to medical or surgical services. Common violations include not covering out-of-network behavioral health services while providing coverage for out-of-network physical health services, according to state officials.
Last year, the administration of Democratic Gov. Josh Shapiro made public a requirement for commercial health insurers that cover autism services to process claims in compliance with both the federal and state parity laws.
The department said it is important for consumers to know if their health insurance company is following the law. They ask people to be cautious if you:
- See a higher co-pay for behavioral health services than you have for physical health services;
- Notice limits on how many times you can see a behavioral health provider, but no limits or different limits on how many times you can see a physical health provider;
- Are required to ask your insurance company for permission (called prior authorization) to access behavioral health services or prescription drugs, but not for physical health services;
- Get coverage for an out-of-network doctor for physical services, but not behavioral health services;
- Are told by your insurance company that it will not pay for behavioral health services your doctor says you need;
- Are asked by your insurance company to try outpatient behavioral health services before it will pay for inpatient behavioral health care; and
- Find your insurance company refusing to pay for substance use disorder treatment in a residential treatment facility because they said it wasn’t “medically necessary.”
Consumers can visit the Pennsylvania Insurance Department’s Mental Health Parity webpage for additional information and resources.
Consumers seeking a mental health service can follow the steps below to determine if their plan covers the services they are seeking:
- Plan Documents: Review your plan documents to determine if you have mental health or substance use disorder coverage. If you have any questions about your coverage, you can also contact your insurer directly.
- Select a Participating Provider: Your insurer may require you seek services from an in-network provider. There are online provider directories, but you may also contact your insurer directly to help you find a provider.
- Prior Authorization: Your insurer may require prior authorization before you receive services. Work with your provider to submit the prior authorization to your insurer. If you are unsure about what services require prior authorization, you may contact your insurer directly to learn more.
- Drug Exception Process: You or your provider may request a drug exception from the insurer to cover a drug not otherwise covered under the plan’s formulary. Health plans providing essential health benefits must have a process in place allowing the consumer or their prescribing physician to request and get access to clinically appropriate medication not covered by their health plan.
Consumers who have been denied a mental health service can follow the below steps to appeal the denial. If life or health is at serious risk, there are options to expedite the process:
- Internal Appeal(s): If the insurer denies a prior authorization request or a submitted claim, review your service denial notice to determine the next step, which may include appealing with your insurer or managed care organization.
- Request for Independent Review: After you receive an internal appeal denial, review your internal appeal denial to determine if you may request an external independent review directly through PID or through your insurer. PID’s External Review Process page offers additional details and the ability to submit your request online.
Pennsylvania Insurance Department officials asked consumers and providers to contact the department if they think a health plan is not meeting parity requirements for mental health and substance use disorder coverage or if a consumer has questions about the benefits to which they are entitled.
Consumers may contact the Pennsylvania Insurance Department Bureau of Consumer Services to file a complaint online or call 1-877-881-6388. The bureau is also available to assist with questions or complaints against an insurance company or an insurance producer (agent/broker).
