The New Ruling on Mental Health-Addictions Coverage: Know Your Rights


The final implementation of the Mental Health Parity and Addiction Act, first signed into law five years ago, was released earlier this month.

The recently released rules ensure that the same health insurance coverage is available for people with mental illness and addiction disorders as for those with physical disorders.

Providing equal coverage

The intention of this federal law is to provide – under a health plan – treatment for mental illness and addiction at the same level of care as other health conditions. This law applies to the new health insurance exchanges as well as small group and individual plans.

The federal ruling is significant because it addresses the medical management methods that insurance companies have applied to limit mental health and addiction coverage. The final parity ruling compels payers of health plans to implement these medical management techniques the same for all conditions, whether physical, mental or addiction-related.

This means a plan that approves 10 treatment visits for a skin condition based on a clinical diagnosis must also approve 10 treatment visits for an addiction condition based on a clinical diagnosis.

The ruling also signifies that if a plan provides for intermediate levels of care for physical ailments, with specific options such as cardiac rehab centers or skilled nursing facilities, the plan also must provide comparable services – residential facilities – for addiction and mental health patients. Formerly, this level of intermediate addictions care has been excluded by most plans.

Demanding rightful claims

Because insurance companies are already looking for ways to work around the new rule and continue limiting access to care, mental health consumers and professionals will need to be knowledgeable and vigilant. We must be aware of the benefits we can expect and must file complaints when health plans are not in compliance. If individuals or their parents do not fight to receive their rightful addiction or mental health claims, nothing will change.

The Parity Implementation Coalition offers a toolkit to assist with the insurance claims appeals process here.

The final parity ruling does not apply to Medicaid-managed care, CHIP (Children’s Medicaid) or to the Medicaid Expansion population.

Source: Bill Moyers


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