When it comes to our well-being, mental health is just as important as physical health. All insurance plans are required by law to cover mental health and substance abuse services. Check with your health plan to find out what options are available.
Parity for Mental Health and Substance Use Disorder Services
All fully insured health plans sold to individuals, small employer groups, and large employer groups must include benefits for mental health and substance use disorder (MH/SUD) services. These benefits must be provided at the same level as benefits provided for physical illness, also known as “parity.” Self-funded health plans (commonly provided by large employers) aren’t required to cover MH/SUD services. If they do include this coverage, it must be provided in parity with benefits for physical illness.
Mental Health Coverage Options
The federal parity law generally applies to the following types of health insurance:
- Employer-sponsored health coverage, for companies with 50 or more employees.
- Coverage purchased through health insurance exchanges that were created under the health care reform law also known as the Affordable Care Act or “Obamacare.”
- Children’s Health Insurance Program (CHIP).
- Most Medicaid programs. (Requirements may vary from program to program. Contact your state Medicaid director if you are not sure whether the federal parity law applies to your Medicaid program.)
Eligibility and Claim Issues
Check your description of plan benefits — it should include information on behavioral health services or coverage for mental health and substance-use disorders. If you still aren’t sure, contact your insurance company directly or contact us at 800-522-0071.
If your mental health claim is denied, always ask why. Your health plan will have a process to review and appeal denied claims. You or your provider may also file a complaint with OID. Read the National Alliance on Mental Illnesses’ tips for what to do if you’re denied care by your insurance.
Consumer Rights and Protections
Health plans that use preferred provider networks (including PPOs, EPOs, and HMOs), must include enough providers within the plan’s service area to allow enrollees reasonable access to in-network providers capable of providing all of the benefits covered under the plan, including:
- emergency care at all times;
- urgent care within 24 hours;
- routine care within two weeks for behavioral health conditions (three weeks for medical);
- primary care within 30 miles (or 60 miles in rural areas for PPOs and EPOs); and
- specialty care (including MH/SUD) within 75 miles.
If a patient or provider believes a health plan is violating the law or isn’t administering the health plan according to the contract, they should file a complaint with OID. OID relies on complaints to learn of violations and identify issues that warrant enforcement actions. Consumers or providers may file a complaint with OID regarding an insurer, HMO, IRO, or URA using OID’s Online Complaint Form at https://www.oid.ok.gov/contact-us/.