Harrisburg, PA – In observance of Mental Health Awareness Month, the Pennsylvania Insurance Department (PID) today reminds consumers about the rights and benefits they are entitled to under Pennsylvania's mental health and substance use disorder parity law. Governor Josh Shapiro has made mental health and substance use disorder treatment parity a priority in his Administration – and in his first budget address, Governor Shapiro directed Pennsylvania Insurance Commissioner Michael Humphreys to make mental health parity a true reality in Pennsylvania and to hold insurers accountable so that mental health benefits are covered fairly.
“Governor Shapiro charged PID with leading the way on making mental health parity a reality in Pennsylvania," said Commissioner Humphreys. “PID has prioritized parity enforcement and public engagement on Pennsylvanians' parity rights. Through our precedent-setting market conduct exams looking at insurance company parity compliance to our front-end review processes and templates that prevent parity violations before they can even present to the public, PID has provided protections for millions of our families and has been a national leader on mental health parity."
Strengthening parity law continues to be a major focus for PID. Last year, the Shapiro Administration announced the requirement for insurers offering commercial health insurance policies that include coverage for autism services to handle claims for those services in a manner that complies with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and Pennsylvania's mental health parity requirements.
Pennsylvania's Health Insurance Coverage Parity and Nondiscrimination Act, which incorporates the federal MHPAEA, requires that health insurers offer equitable access to mental health and substance use disorder services when those services are covered by the plan. Violations of parity laws take many forms, but they generally involve restrictions on mental health and substance use disorder services that do not apply to medical or surgical services, or stricter requirements to approve and receive mental health and substance use disorder treatments. For example, not covering out-of-network behavioral health services but covering out-of-network services for physical conditions.
It is important for consumers to know if their health insurance company is following the law. Be cautious if you:
- See a higher co-pay for behavioral health services than you have for physical health services;
- Notice limits on how many times you can see a behavioral health provider, but no limits or different limits on how many times you can see a physical health provider;
- Are required to ask your insurance company for permission (called prior authorization) to access behavioral health services or prescription drugs, but not for physical health services;
- Get coverage for an out-of-network doctor for physical services, but not behavioral health services;
- Are told by your insurance company that it will not pay for behavioral health services your doctor says you need;
- Are asked by your insurance company to try outpatient behavioral health services before it will pay for inpatient behavioral health care; and
- Find your insurance company refusing to pay for substance use disorder treatment in a residential treatment facility because they said it wasn't "medically necessary."
Consumers can visit the PID's Mental Health Parity webpage for additional information and resources.
Consumers seeking a mental health service can follow the steps below to determine if their plan covers the services they are seeking:
- Plan Documents: Review your plan documents to determine if you have mental health or substance use disorder coverage. If you have any questions about your coverage, you can also contact your insurer directly.
- Select a Participating Provider: Your insurer may require you seek services from an in-network provider. There are online provider directories, but you may also contact your insurer directly to help you find a provider.
- Prior Authorization: Your insurer may require prior authorization before you receive services. Work with your provider to submit the prior authorization to your insurer. If you are unsure about what services require prior authorization, you may contact your insurer directly to learn more.
- Drug Exception Process: You or your provider may request a drug exception from the insurer to cover a drug not otherwise covered under the plan's formulary. Health plans providing essential health benefits must have a process in place allowing the consumer or their prescribing physician to request and get access to clinically appropriate medication not covered by their health plan.
Consumers who have been denied a mental health service can follow the below steps to appeal the denial. If life or health is at serious risk, there are options to expedite the process:
- Internal Appeal(s): If the insurer denies a prior authorization request or a submitted claim, review your service denial notice to determine the next step, which may include appealing with your insurer or managed care organization.
- Request for Independent Review: After you receive an internal appeal denial, review your internal appeal denial to determine if you may request an external independent review directly through PID or through your insurer. PID's External Review Process page offers additional details and the ability to submit your request online.
Since 2022, PID has been leading the nation in developing and implementing sustainable practices to examine health insurance plans for parity compliance before they are sold in the market. Steps taken over the years include:
- Adopted more robust provider network standards for in-network psychiatrists, outpatient counselors, and other providers.
- Encouraged insurers to expand their list of mental health and substance use disorder providers, to help consumers get timely access to services.
- Reviewed plans sold to employers, extending front end mental health parity protections to more than a million covered lives.
- Reviewed plans sold to colleges, reducing barriers for students to access mental health or substance use disorder services.
- insurers to provide more specific information on how they apply cost-sharing and service limitations to mental health and substance use disorder benefits to determine compliance with parity laws.
- Required insurers to illustrate how their medical necessity standards and prior authorization or step therapy processes are compliant with parity laws.
- Developed a new template for insurers to clarify mental health or substance use disorder coverage limitations, restrictions, or exclusions, on benefits.
PID urges consumers and providers to contact the Department if they think a health plan is not meeting parity requirements for mental health and substance use disorder coverage or if a consumer has questions about the benefits to which they are entitled.
Consumers may contact PID's Bureau of Consumer Services to file a complaint online or call 1-877-881-6388. The Bureau is also available to assist with questions or complaints against an insurance company or an insurance producer (agent/broker).
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