Know Your Rights: Parity for Mental Health and Addiction Benefits

Information about the law that protects your mental health and addiction benefits. Read more about these protections here.

Mental Health Parity and Addiction Equity Act of 2008

Health benefits are physical health, mental health, and addiction services paid for by health insurance plans, often called “health insurance.” Generally, the Mental Health Parity and Addiction Equity Act (MHPAEA or “parity”) requires most health insurance plans to apply similar rules to mental health and addiction (Behavioral Health) benefits as they do for medical/surgical benefits – referred to here as “physical health” benefits.

 

Health Insurance Plans and Parity

Most health insurance plans are required by law to offer parity for Behavioral Health benefits. Generally, this includes employer-sponsored group health plans and individual health insurance coverage, including MassHealth plans.

What Parity Means to You

Parity means that financial requirements, such as copays, or how many visits your health insurance plan will pay for, must be comparable for physical health and behavioral health services. Parity also applies to rules related to how behavioral health treatment is accessed and under what conditions treatment is covered (such as whether you need prior authorization from your health plan before starting treatment).

Here are some examples of common limits placed on physical and behavioral health treatment services:

Copays

Deductibles

  • Yearly visit limits
  • Need for prior authorization
  • Proof of medical necessity

Although health insurance benefits may differ, parity requires that the processes be comparable when accessing these benefits. Please call your health insurance plan to find out more information.

Parity Protections

Here are examples of how the protections from this law may benefit you:

Plans must apply comparable copays for behavioral health care and physical health care.

There can be no limit on the number of visits for outpatient MH/SUD care if there is no visit limit for outpatient physical health care.

Prior authorization requirements for behavioral health services must be comparable to or less restrictive than those for physical health serv

If You Want to Learn More about Your Health Insurance Plan

If you have a health insurance plan through work, call your Human Resources (HR) rep for the “summary plan description” and the “summary of benefits and coverage.” You can usually find this number online or on the back of your health insurance card. You may also be able to check your health insurance plan benefits online to see what Behavioral Health Treatment services are covered.

Your Right to Information

Your health insurance plan will provide information to you about all the benefits it offers. You have the right to request this information from your health insurance plan. This includes criteria the plan uses to decide if a service or treatment is medically necessary. If your plan denies payment for MH/SUD services, your plan must give you a written explanation of the reason for the denial and must provide more information upon request.

Your Right to Appeal a Claim

If your health plan denies a claim, you have the right to appeal the denied claim. This means you can ask your health plan to look again at its decision, and perhaps reverse the decision and pay the claim. Call your health plan to ask how to submit a request to appeal a claim.

Parity Resources

For more about the Federal parity law, go to the Department of Labor (DOL) Mental Health Parity page

or call toll-free at 1-866-444-3272 to speak to a DOL benefits advisor.

For assistance with parity issues in Massachusetts, please contact either the Massachusetts Division of Insurance at 1-877-563-4467, MassHealth at 1-800-841-2900, or the BSAS Helpline at https://helplinema.org/ or call at 1-800-327-5050 depending on your coverage.

For additional resources go to Substance Abuse and Mental Health Services Administration (SAMHSA) page and the Centers for Medicare & Medicaid Services (CMS) page.

 

 

 

 

 

 

 

 

Consumer Guide – Behavioral Health Treatment

 Consumer Guide

How to access Behavioral Health Treatment through Your Health Insurance Plan

We created this Consumer guide to help you make good choices about getting the care you need for you and your family. On the back of this guide we’ve provided definitions of words that health insurance plans use. These definitions should help you understand this process.

  • Know Your Health Insurance Plan
  • It is important to know what services your health insurance plan covers. In order to gain more information, please contact your health insurance plan to verify your coverage. Information about your specific health insurance plan’s coverage is listed in your policy or certificate of coverage. In addition, your health insurance carrier should provide a Summary of Benefits and Coverage (SBC) that lists both coverage and cost shares in an easy to read format.

When looking for information about your health insurance plan, here are some important questions you should ask:

  • What is the difference between in-network and out-of-network, and why does it matter?
    • In-network providers have agreed to a rate with your health insurance plan which will not exceed the cost of your copay, deductible, or coinsurance amounts.
    • Out-of-network providers have not agreed on a rate with the health insurance plan. This type of provider can bill you for an amount beyond what your health insurance plan pays.
  • Does your health insurance plan cover out-of-network providers?
  • What are the copays if you use an out-of-network provider?
  • What services require prior authorization under your health insurance plan?
    • Prior authorization is when the health insurance plan requires you and your Primary Care Provider to seek medical necessity approval before receiving services.
  • What if there are no in network options that fit your needs in your health insurance plan?
  • Seek “Medical Necessity” Approval
  • Health insurance carriers approve services they determine are “medically necessary”. Some medical services require prior-authorization, this means that the health insurance plan must approve treatment before the patients receives services. It is important that your Primary Care Provider (PCP) is involved in this process.
  • It is important to note that if you are denied service, you have a right to appeal the denial.
  • For more information on how to appeal denials you should contact your health insurance plan.
  • Determine Your Out-of-Pocket Expenses

 

Before beginning treatment with a provider that is not covered by your plan, it is important to understand all of your out-of-pocket expenses.

  • You should call your health insurance plan to be sure that your plan offers the option to use out-of-network providers.
  • It is important to remember that you are responsible to pay for any charges that exceed the allowed amount as set by your health insurance plan.
  • Make Informed Decisions

 

As a consumer it is important to make sure you have all the facts and Information before you make any choices on behavioral health care.

Important Tips for Consumers

  • Start with your primary care physician and ask them to recommend other providers within the plan’s network.
  • Research the providers in your area with your health insurer.
  • Consider using an in-network provider. It provides the most consumer protection and it costs less for you.
  • Have services approved in advance whenever possible. Please make a note of who you spoke to and the date and time of each call.
  • Use the glossary on this page to help you understand the terms that are used by your health insurer.
  • Remember, if you have any questions, call your health insurance plan.

 

 

Glossary

Coinsurance- Your share of the costs of a covered health care service, which is usually calculated as a percent.

Copay- A fixed amount you pay for a covered health care service, usually when you receive the service.

Cost Sharing- The amount you pay for health care expenses that are not covered by your health insurer including copayments, deductibles, coinsurance, and provider charges over the allowed amount.

Deductible- A set amount you have to pay every year toward your medical bills.  If you have a deductible, some health insurance plans may not start paying your medical bills until you have met your deductible.

Health Insurance Plan– An insurance company that provides health insurance coverage that pays for medical, surgical and behavioral health expenses incurred by the insured or member. The Health Insurance Plan may reimburse the insured or member for expenses incurred from illness or injury, or pay the Provider of care directly.

Medical Necessity- Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Prior-Authorization- A decision by your health insurer that a health care service is medically necessary, this means that the health insurance plan must approve treatment before the patients receives services. This is sometimes called prior authorization, prior approval or precertification.

Provider- A physician licensed to practice medicine in all its branches, licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapist, licensed speech language pathologist, or other licensed or certified professional.

 

  • In-Network Provider- The facilities, health care practitioners and suppliers your health insurer has contracted with to provide health care services to you at a discounted price.
  • Out-of-Network Provider- The facilities, health care practitioners and suppliers who do not have a contract with your health insurer to provide services to you. You will pay more to see an out-of-network provider.
  • Primary Care Provider (PCP) – A physician, nurse practitioner, or physician’s assistant who is the first line of care for a patient. The PCP will help you get the services you need.
Type of Insurance Phone Number Website By Mail
1-800-841-2900 www.mass.gov/masshealth TBD
1-877-623-6765 https://www.mahealthconnector.org/ombudsman-contact-form Health Connector Ombudsman Office

PO Box 960484

Boston, MA 02109-9997

 

All others Division of Insurance

 

(617) 521-7794

 

http://www.mass.gov/ocabr/docs/doi/consumer/css-complaint-form.pdf Office of Consumer Affairs and Regulations

1000 Washington St , Ste. 810

Boston, MA 02118-6200

 

 

 

 

Flex YOUTH Focus Group

Flex Youth Focus Group Invite

 

DMH is changing its Individual and Family Flexible Support Services and wants input from youth!

 

Please come to our youth meeting to help us better understand what youth need for their mental health needs. We also want to hear ideas for improving DMH’s community based services.

 

Please attend DMH’s meeting:

 

DATE: 10/25/2017

TIME: 1PM to 230PM

PLACE: DMH Central MA Area Office

361 Plantation St

Worcester, MA 01605

 

We look forward to hearing your ideas and your thoughts.  Here are some of the questions we’re interested in discussing:

 

 

  1. What mental health and wellbeing needs do you and your parents have that are not currently being met by services available in your community?

 

 

  1. What do you need to fully support and your mental health needs living at home? What do you need to live happily at home?

 

 

  1. What has been your experience getting the services and supports you currently receive?

 

 

To RSVP and if you have any questions about the meeting, please contact:

Nicole Palmer at Nicole.palmer@massmail.state.ma.us or 774-420-3144

Flex Family Focus Group

Flex Family Focus Group Invite

 

DMH is changing its Individual and Family Flexible Support Services and wants input from parents!

 

Please come to our parent meeting to help us better understand what families need for their children with mental health needs. We also want to hear ideas for improving DMH’s community based services.

 

Please attend DMH’s parent meeting:

 

DATE: 10/25/2017

TIME: 1PM to 230PM

PLACE: DMH Central MA Area Office

361 Plantation St

Worcester, MA 01605

 

We look forward to hearing your ideas and your thoughts.  Here are some of the questions we’re interested in discussing:

 

 

  1. What mental health and wellbeing needs do you and your child have that are not currently being met by services available in your community?

 

 

  1. What do you need to fully support and provide for your child with mental health needs living at home? What does your child need to live happily at home?

 

 

  1. What has been your experience getting the services and supports your child currently receives?

 

 

To RSVP and if you have any questions about the meeting, please contact:

Nicole Palmer at Nicole.palmer@massmail.state.ma.us or 774-420-3144

Making a DIY “Coping Tools Box”! FREE 2-WEEK EVENT

Join parents and caregivers on

 October 16TH and 23RD from 6:30pm to 8:00pm

Bring your child/adolescent or come alone and make a

DIY “Coping Tools Box”

that will help relax and calm you and your child!

All supplies are provided free of charge!
Group will meet at  Wayside at 431 River Street in Waltham

RESERVATIONS AND ATTENDANCE BOTH NIGHTS IS REQUIRED.

PLEASE RSVP TO KELLEY DARON 781-966-5644 OR KELLEY_DARON@WAYSIDEYOUTH.ORG

ON OR BEFORE MONDAY 10/9

 

Workshop Series for Parents of Young Adults

Going on Now! You are invited!

6 Week Workshop Series for Parents of Young Adults

How to Support Your Young Adult

While Creating the Ground Rules for Living Together

Coinciding with a

6 Week Peer Support Group for Young Adults

Facilitated by a young adult with lived experience

 

Parents will meet at Wayside Youth & Family Support Network

88 Lincoln Street, Framingham

 

Young Adults will meet at TEMPO

68 Henry Street, Framingham

 

Meetings will be held from

6pm-7:30pm on the following dates:

September 20th, October 4th, November 1st,

November 15th, November 29th, and December 13th  

 

For registration and information

Contact Ann Killion, 508-469-3207

or

ann_killion@waysideyouth.org

Child & Adolescent Psychiatry Education Day

The Massachusetts General Hospital Department of Psychiatry invites you to attend a free patient and family education symposium Child & Adolescent Psychiatry Education Day.

This free event will provide an opportunity for people with substance use disorders, their family, friends, clinicians, and others to learn about substance use disorders and become actively involved in the treatment and recovery of someone they care about.

This exciting event will offer an update on new research findings and important clinical topics for parents, their family, friends, and others. The morning will feature various topics such as; Obsessive Compulsive, Mood, and Substance Use. We will also discuss Learning Disabilities and Working with Schools, as well as, Behavioral Interventions for Children with Food Allergies.

In the afternoon, our discussions will focus on; Parenting Children with Anxiety and Personality Disorders, Launching Transitional Age Youth, a Family Discussion and Resiliency Training for Youth.

We will offer interactive panel discussions throughout the day that include our presenting faculty and a parent panel. These times will give patients and families an opportunity to offer comments and ask questions.

This program is made possible through the generosity of the Joan and Leonard Engle Family Foundation.

Presented by

  • Massachusetts General Hospital Department of Psychiatry
  • The Massachusetts General Hospital Psychiatry Academy

Target Audience: This free educational program is designed exclusively for patients, families, friends, and their clinicians.

This program is not offered for continuing education credit

 Topics:

Obsessive compulsive behavior

Mood issues

  • Substance use
  • Learning disabilities
  • Working with schools
  • Behavioral interventions for children with food allergies
  • Parenting children with anxiety and personality disorders
  • Resiliency training for youth

Date: Saturday, September 16, 2017

9:45 am – 4:00 pm, with check-in from 9:00 am – 9:45 am

Complimentary coffee, tea, and lunch will be served.

Location:

The Starr Center Auditorium

Charles River Plaza, 185 Cambridge Street, 2nd floor

Boston, MA, 02114

The Starr Center Auditorium is located on the 2nd floor in the Schepens Eye Research Institute. Look for the Richard B. Simches Research Center building located in the Charles River Plaza next to Whole Foods.

Cost:

The program is offered at no charge for patients and their families.

Transportation and Parking: Parking will not be discounted or validated. 

Because of the hospital’s close proximity to the Charles/Mass General Red Line Station, the use of public transportation for this event is highly recommended.

Registration:

Seating is limited and pre-registration is required. To learn more about the program and register,  click here or call 866-644-7792.

For more information about the patient and family education series, visit www.mghpatientfamily.org.

Contact Information phone: 866-644-7792 mghcme@mgh.harvard.edu

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~