Behavioral health parity laws
Equal coverage of treatment for mental health and addiction
What is parity for behavioral health?
Insurance companies have historically provided better coverage for medical issues than they have for behavioral issues, such as mental and substance-abuse disorders (SUDs) and conditions like autism or attention-deficit disorder. To help patients get treatment for behavioral health, New York state and federal laws require health insurers to provide about the same level of benefits for behavioral health as they do for medical care. This is called parity.
Federal and state laws protect parity
The federal Mental Health Parity and Addiction Equity Act (now part of New York law) requires insurers to provide behavioral health coverage similar to their coverage of medical or surgical treatments:
- quantitative (numerical) limits on treatment, such as:
- how often a patient receives treatment
- the number of days they can stay in a facility
- the number of office visits they are allowed
- non-quantitative treatment limitations, such as:
- requiring treatments to be reviewed for medical necessity
- coverage of prescription drugs
- how the health plan ensures an adequate network of providers
- provider-reimbursement rates
- requiring that one treatment must fail before a patient is allowed to try another
- financial requirements, such as deductibles, copayments, coinsurance, and out-of-pocket expenses
- annual and lifetime dollar limits on benefits
New York law protects consumers in even more ways
For behavioral health treatment, insurers must:
- make available the criteria they use to decide whether treatments are medically necessary
- maintain an accurate online provider directory that shows whether each provider is accepting new patients or has any restrictions
- provide an analysis comparing their behavioral health coverage with their medical coverage
For mental health treatment, insurers must:
- use medical-necessity criteria approved by the Office of Mental Health (OMH)
- have medical-necessity reviews done only by licensed clinicians who have experience delivering mental health treatment
- for inpatients younger than 18 at in-network facilities licensed by OMH: not conduct medical-necessity reviews for the first 14 days after admission for a mental health condition
For treatment of substance use disorders (SUDs), insurers must:
- for treatment provided in New York: use the level-of-care determination (LOCADTR) tool created by the Office of Addiction Services and Supports (OASAS)
- at OASAS-licensed facilities: not conduct medical-necessity reviews during the first 28 days of in-network treatment for SUDs
- not require prior approval for any medication approved for SUD treatment on the statewide list (formulary) of covered drugs
Is your health plan breaking the law?
Look for differences in how your plan treats behavioral health services and medical services, such as:
- higher copayments
- separate deductibles for behavioral health
- specific services that are not covered, such as residential treatment
- different preauthorization requirements
Other issues that should raise red flags include:
- requirements that a treatment must fail before you can try another
- denials for coverage if you do not complete treatment or if the plan decides you will not improve
- higher denial rates for behavioral health
- reduced payments for out-of-network providers
- insufficient or incorrect information in denial letters
- refusing to provide medical-necessity criteria or using criteria that do not match your condition
- failure to consult with your provider or to consider medical evidence the provider has supplied
- refusal to reimburse treatment by a licensed mental health provider
- inability to access an in-network mental health provider who can see you in a reasonable amount of time at a location you can access
- limits on the number of days or visits for behavioral health
Protect your rights
Keep good records and follow your health plan’s rules:
- Make sure your provider gets authorization from your health plan, if required.
- For each coverage request, make sure your provider has a copy of the plan’s medical-necessity criteria, explains to the plan why you meet the criteria, and submits medical records.
- For each contact with the health plan, ask for the name, title, and ID number of the person you dealt with, the date and time of the contact, and what the person said. Ask for written confirmation.
Were you denied coverage?
Check the denial letter for mistakes and let the plan know if there are any.
Ask your provider to submit a letter of medical necessity, including facts and a point-by-point explanation showing that you meet the relevant medical-necessity criteria.
If possible, put requests for information in writing.
Upon request, the plan must provide you with the following:
- a written, detailed explanation of the denial
- a comprehensive set of plan documents, your claim file, your records, and other information relevant to your claim
- documents comparing the plan’s medical-necessity criteria and utilization-review processes for medical benefits versus behavioral health benefits
- confirmation that the plan’s medical-necessity criteria address your condition and have been approved by OASAS or OMH
- a description of the qualifications of the reviewer who issued the denial, and confirmation that they have the same specialty as your provider
Appeals
Either you or your provider may appeal a denied claim, by phone or in writing. Generally there are two levels of appeal:
Internal appeals
These are decided by your plan, within 45 days.
For continued treatment, or if your provider indicates an immediate appeal is necessary, the plan must decide within two business days.
For inpatient SUD treatment, the plan must decide within 24 hours.
While it is working on your appeal, your plan must continue your coverage.
If you are an inpatient receiving SUD treatment under a New York plan, and if you submit your appeal at least 24 hours before you are discharged, the plan cannot deny you coverage while a decision is pending.
External appeals
These are decided by a neutral expert. You can usually request an external appeal if:
- You were denied for medical-necessity reasons.
- Your plan refused to pay for an experimental treatment.
- Your plan denied your request to be treated by an out-of-network provider at in-network rates.
If your provider states that a delay in providing treatment would pose an imminent or serious threat to your health, your appeal can be expedited. This means it must be decided within 72 hours.
Note: While you are waiting for your appeal to be completed, do not agree to pay your provider directly.
Tips:
- Take the time to understand what the behavioral health parity laws require.
- Review your health plan’s benefits carefully.
- Make sure that your provider has your health plan’s medical-necessity criteria and that they supply information about your care to the plan as requested.
- Ask your health plan for information about any denials you receive. You can appeal those denials yourself, or ask your provider to appeal them for you.
Resources
Office of the New York State Attorney General
Health Care Bureau Helpline: 800-428-9071
File a health care complaint
New York State Department of Financial Services
Consumer Hotline: 800-342-3736
Learn more about an external appeal
United States Department of Labor Employee Benefits Security Administration
Eastern New York regional offices: 212-607-8600
Central and Western New York: 617-595-9600
File a U.S. Department of Labor complaint