If you have an employee benefit plan, it should follow the minimum standards set by the Employee Retirement Income Security Act of 1974 (ERISA). This federal law aims to protect the interests of employees and their beneficiaries by setting standards for retirement and health plans in private industry, including mental health and substance use disorder (MH/SUD) services.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that MH/SUD benefits must be equal to medical and surgical benefits in terms of:
Financial requirements
The financial requirements for MH/SUD benefits must not be higher than those for medical and surgical benefits. This includes:
- Copayments: This is the fixed amount you pay for a covered health care service. If you pay $20 for a primary care visit, you should not pay more than $20 for a therapy session.
- Deductibles: The amount you pay out of pocket for health care services before your insurance starts to pay. You should not have a separate, higher deductible for mental health care.
Your out-of-pocket maximum – which is the most you should have to pay for covered health care services in a plan year – must also include MH/SUD services.
Treatment limits
ERISA plans must ensure that treatment limits for mental health services are comparable to those for medical services. This includes:
- Consultations
- Number of days covered for inpatient health care
- Number of therapy sessions
- Duration of treatment
For example, if your plan allows unlimited visits to a primary care physician, it should also allow unlimited visits to a mental health provider.
Advocate for the benefits you deserve
If insurance companies are placing undue restrictions or denying your claim for mental health benefits, don’t hesitate to question it. You have the right to a full explanation and to appeal the decision.
