State and federal parity laws require most health insurers to cover mental health and substance abuse treatment for children under the same terms and conditions as they cover other medical services. However, problems persist. Families report that denials of coverage, burdensome health plan approval processes, inadequate behavioral health provider networks, and other issues continue to block their access to appropriate care. CMHC advocates to improve oversight and enforcement of these important laws. If you feel that your rights under the parity law have been violated, you please contact Health Law Advocates.
This federal law prevents certain health plans and health insurance issuers that provide coverage for mental health or substance use disorders from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. Some specific requirements of the law include:
- Financial requirements, like co-payments and deductibles, for behavioral health services may not be more restrictive than those for medical or surgical services.
- Quantitative treatment limitations, like the number of visits per year, and non-quantitative treatment limitations, like prior authorization requirements, may not be more restrictive for behavioral health services.
- Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD benefits must be disclosed upon request.
- Non-discriminatory access to out-of-network providers.
The federal parity law applies to large group employer-sponsored health plans (sometimes called “ERISA plans”), small group and individual plans sold on the health insurance exchange, state employee plans through the Group Insurance Commission, and Medicaid (MassHealth) plans offered through a Managed Care Organization (MCO).
This state law requires certain health insurers to cover the diagnosis and treatment of certain mental disorders to the same extent that they cover the diagnosis and treatment of physical disorders. The law makes it illegal for some health insurers to place stricter annual or lifetime dollar or unit of service limitations on coverage of qualifying mental disorders that differ from the limitations on coverage of physical conditions. The law also provides for minimum outpatient and inpatient benefits for those disorders not required to be treated the same as physical ailments. Some specific requirements of the law include:
- Covered plans must provide non-discriminatory coverage for the diagnosis and treatment of certain behavioral health conditions.
- For adults, covered plans must provide coverage for the diagnosis and treatment of “biologically-based mental illnesses.” A list of these conditions is included in the law. For adults who do not have a biologically-based mental illness, covered health plans must provide at least 60 days of inpatient treatment, and at least 24 outpatient mental health visits per year.
- For children and adolescents under 19, covered health plans must provide non-discriminatory coverage for the diagnosis and treatment of any mental, behavioral, or emotional disorder that is described in the most recent edition of the DSM, and which substantially interferes with or substantially limits a child’s functioning and social interactions.
- Under the Massachusetts Parity law, covered health plans must cover the full scope of services to treat a behavioral health condition, including inpatient, outpatient, and intermediate treatment, so long as it is medically necessary. Learn more about coverage of intermediate services.
- The Massachusetts Parity Law applies to fully-insured Massachusetts group and non-group health plans, and state employee plans through the Group Insurance Commission.