For more on the law requiring equal health coverage, see Parity for Mental Health and Substance Use Disorders.
If your plan covers some mental health or substance use disorder services, then that coverage must be essentially equal to coverage offered for similar medical services. This generally means that the limits that are applied to mental health or substance use disorder services can’t be more restrictive than the limits applied to medical and surgical services.
Examples of unequal coverage
Your plan covers medical office visits to in-network and out-of-network physicians. For behavioral health counseling, the plan covers office visits to in-network counselors only.
Because the plan offers coverage of a mental health service (behavioral health counseling), then it must cover office visits to both in-network and out-of-network counselors, just like it does for medical office visits.
Your plan covers an unlimited number of medical office visits each year, but behavioral health counseling is limited to 6 visits per year (meaning only 6 visits will be covered by your insurance).
Coverage for behavioral health office visits may not be limited or capped because there is no similar limit or cap on visits for medical services.
Your plan covers in-network and out-of-network hospital stays, but only covers psychiatric hospital stays if they are in-network and you receive prior authorization before being admitted.
Prior authorization can’t be required for psychiatric hospital stays if it is not also required for general hospital stays. Also, coverage for psychiatric hospital stays can’t be limited to in-network hospitals where general hospital stays are covered at in- and out-of-network hospitals.
Your plan will cover hospital stays that last more than 3 days if prior authorization is given by the insurance company. Your plan will cover psychiatric hospital stays that last more than 24 hours if prior authorization is given by the insurance company.
Here, the plan requires a prior authorization for both general and psychiatric stays, but the requirement for psychiatric hospital stays is more restrictive. General hospital stays are automatically covered for up to 72 hours, but psychiatric stays only have automatic coverage for up to 24 hours. Prior authorization requirements for mental health services must be comparable to or less restrictive than the prior authorization requirements for general, physical health services.
“Network” is the collection of facilities, physicians, other providers, and suppliers that contract with your insurer to provide healthcare services.
“Provider” is a health care professional such as a doctor, nurse, or behavioral health professional.
“Prior Authorization” is a requirement from your insurance company that your provider get preapproval from your plan before it will cover the cost of a specific item or service.