Federal and Oklahoma state law requires that health insurance carriers cover services for mental and behavioral health conditions the same way they cover other medical conditions, like diabetes or heart disease. This is called “parity.” Parity is about equal and fair treatment for people who need mental and behavioral health care.

Parity laws prohibit health insurance plans from being more restrictive in providing mental health, behavioral health, and substance use disorder benefits than they would be for medical and surgical benefits, with respect to the following.

• What you pay: Copays, coinsurance, deductibles, and out-of-pocket maximums (collectively referred to as cost-sharing)
• How much treatment you can get: Limitations on the use of services, such as limits on the number of inpatient or outpatient visits that are covered
• Use of management tools: Such as pre-authorization requirements
• Which doctors you can see: Adequate providers in-network to provide necessary services, coverage for out-of-network providers, and considerations for geographic location
• Determining criteria: This is what the insurance company uses to determine what is considered medically necessary treatment.

“Mental Health” vs. “Behavioral Health” – Mental health and behavioral health are sometimes used interchangeably, but they’re not quite the same. Mental health refers to a person’s psychological and/or emotional well-being, whereas behavioral health is an umbrella term that includes a variety of factors that impact a person’s well-being, development, and behavior. This includes, but is not limited to, mental health conditions, substance use disorders, eating habits, and external factors that influence a person’s well-being, like poverty, housing insecurity, and trauma.

In many cases, yes. There are only a few exceptions of health plans that DO NOT have to follow Federal parity laws:

• Most of Medicare does not have to follow parity laws (the exceptions are Medicare’s outpatient mental health services cost-sharing – what you, the consumer has to pay – and Medicare Advantage plans: both have to follow parity laws)
• Health plans that were created and purchased before March 23, 2010, do not have to follow parity laws. These are called “grandfathered” plans, as they were allowed to continue after the Affordable Care Act became law in 2010, or “grandfathered” under the old rules. These could be employer plans or individual (non-employer) plans.

All other types of health insurance plans must follow State and Federal parity laws. These include employer plans (both large and small employer plans), individual plans (meaning not from an employer), student health plans, Oklahoma Medicaid (known as SoonerCare) and Children’s Health Insurance Program (CHIP).

If you are unsure about what type of plan you have, ask your insurance company or agent, your plan administrator, your employer (specifically your human resources department), or the Insurance Department – 405-521-2828/800-522-0071/oid.ok.gov.

While it should not be harder or more expensive to get mental / behavioral health treatment than physical health treatment, it can be hard to identify parity violations or know if you’re being unfairly denied coverage. The following examples can help you to determine if there has been a violation of your mental / behavioral health protections.

• You are charged a higher copay or coinsurance for mental / behavioral health services.
• A limit is placed on the number of visits or days of mental / behavioral treatment, inpatient or outpatient.
• Mental / behavioral health services have separate deductibles from medical services.
• You can’t get the level of behavioral care your doctor says you need unless you try something less expensive first. Oklahoma state law further expands patient protections around such requirements, often called step-therapy or fail-first requirements.
• Prescribed medications for behavioral health treatment cost more than medications for other kinds of conditions.
• You are required to get prior authorization for behavioral health treatment, but that’s not required for medical treatment or, you were able to start treatment, but have to keep getting authorization to continue.
• Your doctor says you need residential treatment, but your plan won’t pay for residential treatment for substance abuse or mental health issues; or your plan won’t pay for behavioral treatment outside of Oklahoma, even though you can get medical treatment outside of the state.

In addition to the information in this guide, you can:

• Ask your health care provider to help find out why you have been denied treatment, denied reimbursement, or why your treatment has been reduced or limited. Your provider can submit a letter to the insurance company that explains why the requested treatment is medically necessary.
• You are also entitled to more information from your insurance company to help you decide whether you want to file an internal appeal.
  • A denial letter explaining the reason(s) for denial – Always ask for the denial in writing.
  • An explanation-of-benefits form that explains what was requested and denied – To help you consider whether the parity law has been violated, you can compare limitations for behavioral treatment with those for medical services.
  • The medical necessity criteria your insurer uses to decide whether a type of treatment is medically necessary – You and your health care provider can request this information and can request not only the medical necessity criteria for behavioral benefits, but also the criteria for comparable medical benefits, so that the standards can be compared. You will need any records and bills from your treatment to do this comparison.
• You may decide to file an appeal stating your insurance company violated parity laws. You can also file an appeal that claims the company did not make the right decision about what was medically necessary.
• You can also file a complaint with the Oklahoma Insurance Department. Contact the Department at 405-521-2828/800-522-0071/oid.ok.gov .

Both Federal and Oklahoma state law provide protections for consumers accessing mental / behavioral health services.

• Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) – This Federal law – also called the Parity Law – requires health insurance coverage for mental health and/or substance use disorder conditions comparable to what patients would receive for coverage of medical/surgical services.
• Affordable Care Act (ACA) – While the ACA gave people better access to health insurance and health care, it also helps to further enforce mental health parity. It requires that all plans (except grandfathered plans created before the ACA) cover mental health and substance abuse services as essential health benefits, including behavioral health treatment, such as psychotherapy and counseling, mental and behavioral health inpatient services, and substance use disorder treatment. And it eliminated annual and lifetime spending limits.

36 O.S. § 6060.11 (Mental Health and Substance Abuse (Benefits Required)– The Oklahoma State Legislature passed this statute to add to the State’s mental health parity laws for private health insurance. It gives the Insurance Department additional authority over health insurance companies to enforce parity.

Understanding Parity : A Guide to Resources for Families and Caregivers