The ministry said it is important for consumers to know whether their health insurance company is complying with the law. The ministry urges consumers to be wary of the following:
The Pennsylvania Department of Insurance recently issued a reminder about the rights and benefits available to Pennsylvania residents as part of the state’s Mental Health and Substance Use Disorder Parity Act.
The state’s health insurance coverage parity and nondiscrimination laws are consistent with the federal Mental Health Parity and Addiction Equality Act of 2008 (MHPAEA), which requires health insurers to provide equal access to mental health and substance use disorder services included in their plans.
The law ensures that insurers do not impose more stringent requirements on these services than they do on medical or surgical services. Common violations, state officials said, include covering out-of-network physical health services but not covering out-of-network behavioral health services.
Last year, Democratic Gov. Josh Shapiro’s administration unveiled a plan to require private health insurers that cover autism services to process claims in compliance with both federal and state parity laws.
The ministry said it is important for consumers to know whether their health insurance company is complying with the law. The ministry urges consumers to be wary of the following:
- Copayments for behavioral health services are higher than copayments for physical health services.
- It is important to note that there are limits on the number of visits with behavioral health providers, but there are no limits or different limits on the number of visits with physical health providers.
- Behavioral health services and prescription medications require you to get authorization (pre-authorization) from your insurance company, but physical health services do not.
- Out-of-network physician insurance will cover physical services but not behavioral health services.
- When your doctor tells you that your insurance company won’t pay for the behavioral health services you need.
- Before paying for inpatient behavioral health care, your insurance company will require you to try outpatient behavioral health services.
- It turns out insurance companies are refusing to pay for substance use disorder treatment in residential treatment facilities because it’s “not medically necessary.”
Consumers can visit the Pennsylvania Department of Insurance’s Mental Health Parity webpage for additional information and resources.
consumer Seeking Mental Health Services You can check if your plan includes the services you want by following the steps below.
- Planning Documents: Check your plan documents to see if your plan covers mental illness or substance use disorder, and you can also contact your insurance company directly if you have questions about your coverage.
- Select a participating provider: Some insurance companies require you to get services from an in-network provider. There are online provider directories, but you can also contact your insurance company directly to find a provider.
- Pre-approval: Insurance companies may require pre-authorization before you receive services. Work with your provider to submit pre-authorization to your insurance company. If you are unsure of which services require pre-authorization, contact your insurance company directly for more information.
- Drug Exception Process: You or your health care provider may apply for a drug exception from your insurer to cover a drug that is not covered by your health plan’s prescription. Health plans that provide essential health benefits must have a process in place that allows consumers or prescribers to request and obtain clinically appropriate drugs that are not covered by the health plan.
Consumers Being denied mental health services To appeal a denial, you can follow the steps below: If your life or health is at serious risk, you have the option to expedite the process.
- Internal Appeal: If the insurance company denies your prior authorization request or the claim you submitted, review the denial of service notice to determine next steps, which may include filing an appeal with the insurance company or managed care organization.
- Request for an independent review: Once you receive the internal appeal denial, review the internal appeal denial to see if you can request an external, independent review either directly through PID or through your insurance company. PID’s external review process page provides additional details and the ability to submit a request online.
Pennsylvania Department of Insurance officials urged consumers and health care providers to contact the department if they believe their health plan does not meet parity requirements for mental health and substance use disorder coverage or if consumers have questions about the benefits to which they are entitled.
Consumers may contact the Pennsylvania Department of Insurance’s Bureau of Consumer Services to file a complaint online or by calling 1-877-881-6388. The Bureau also responds to questions and complaints against insurance companies or insurance agents (agents/brokers).
