Since the passage of two federal laws, the Mental Health Parity and Addiction Equity Act and the Patient Protection and Affordable Care Act, consumers now have improved access to mental health and substance use disorder (MH/SUD) treatments and services. As a result, your health insurance plan offers a variety of benefits which allow you to access licensed mental health professionals at a reasonable cost. This Health Insurance Fact Sheet provided by the Department of Insurance, Securities and Banking, includes a summary of Mental Health Parity, the protections that come with it, and what to do if you are having trouble using health services in the District of Columbia.
WHAT IS MENTAL HEALTH PARITY?
Mental Health Parity means that your health insurance must treat mental health conditions, like anxiety and depression, the same as they treat physical health conditions, like diabetes or a broken leg.
EXAMPLES OF HEALTH INSURANCE PLANS WHICH HAVE TO COMPLY WITH MENTAL HEALTH PARITY:
- Plans bought on DC Health Link
- Plans bought through your employer
EXAMPLES OF LICENSED PROFESSIONALS WHO OFFER COVERED MH/SUD SERVICES
Review your provider directory to see which of the following may be in your plan’s network:
Certified Psychiatric Nurse
Masters-level psychiatric nurses with an added certification in behavioral health by the American Nurses Credentialing Center. They may perform psychotherapy and manage medications.
Certified Marriage and
Masters-level degree in counseling with an emphasis on family and marriage therapy. They may perform individual counseling and group therapy, but they may not prescribe medication.
Clinical Social Workers
Masters-level degree in social work with additional training in psychotherapy and counseling. They cannot prescribe medication.
Doctoral-level degree in psychology (Ph.D. or Psy.D.). They perform psychotherapy, psychological testing and counseling services, but usually cannot prescribe medication.
Master's-level service providers, trained to work with individuals, families, and groups in treating mental, behavioral, and emotional problems and disorders. They cannot prescribe medication.
Physicians who have earned a general medical degree (M.D. or D.O.) and then completed advanced residency training in psychiatry. Commonly, the psychiatrist will work in collaboration with another provider type above.
Substance Use Counselor
Counselors evaluate clients' mental and physical health, addictive behaviors and openness to treatment. On completing an evaluation, the counselor helps the client develop treatment and recovery plans, as well as identifies behaviors that interfere with both processes.
BENEFITS AND SERVICES THAT MUST BE COVERED EQUALLY:
Mental Health Parity applies to both Financial Requirements (co-pays, coinsurance and deductibles) and Treatment Limits (number of visits covered per year) for the following categories:
CATEGORY EXAMPLES OF SERVICES WHICH SHOULD BE TREATED EQUALLY*
Surgery to repair a broken bone vs. residential drug rehabilitation
Dermatologist appointment vs. psychiatrist appointment
Heart attack care vs. observation and stabilization after attempted suicide
All drugs used to treat HIV are preferred brand, while all drugs used to treat depression are on the specialty tier.
*Note: Actual regulatory review of plans requires a comprehensive view of benefits and services, and may not be as simple or clear as the one-off examples provided in this table.
Health insurance companies may establish rules for how you access care. Under Mental Health Parity, these rules cannot be more limiting for mental health and substance use disorder benefits than they are for medical benefits. Some examples of generally allowable rules, but which may not be more restrictive for MH/SUD than medical coverage include:
- Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as “step therapy”);
- Exclusions based on failure to complete a course of treatment.
MORE EXAMPLES OF POSSIBLE VIOLATIONS OF PARITY
Medical Necessity: After your appointment with a psychiatrist, your health insurer sends you a letter stating it will not pay the claim because the service or treatment was not “medically necessary.” Generally, a MH/SUD service or treatment is medically necessary if:
- Taught in accredited colleges and universities;
- Rendered for the diagnosis or treatment of an actual or existing medical condition (unless being provided as a preventive service);
- and The service or treatment is not experimental or investigational (unless other appropriate services or treatments have been tried first and determined ineffective).
Prescription Drugs: Your plan places all drugs used to treat depression at the specialty tier, which means that the drugs will cost you more
money than if the drugs were placed at other tiers for generic drugs or preferred brand name drugs.
Reimbursement Rates: Your plan pays an out-of-network allergist, gynecologist, or dermatologist at 80% of their normal rate, while only pay-
ing an out-of-network mental health professional at 60% of their normal rate.
Provider Network: While searching your plan’s provider directory, you find it more difficult to make an appointment with an in-network mental health professional (including finding a provider who is accepting new patients, finding a provider within 30 minutes of your home, or finding a provider who can see you in less than 30 days) than for other providers
Cost: Your plan charges a higher out-of-pocket payment (co-payments or co-insurance) for mental health professionals than for other specialty providers (e.g. allergists, OB/GYN, or dermatologists).
REPORT A POSSIBLE VIOLATION
Are you having trouble accessing mental health or substance use disorder providers, services or treatments? If so, you may file a complaint with the District of Columbia Department of Insurance, Securities and Banking’s at disb.dc.gov or call (202)-727-8000.