Mental Health Parity
Learn how your health insurance might change in 2010
A new law goes into effect January 1, 2010, and it will likely impact the health benefits you receive for mental health care. Previously, patients were responsible for a greater share of mental health and substance use treatment costs. These coverage limitations will now end. Get the facts and get help.
Click here to download the PDF version of this flyer.
Frequently Asked Questions
How does the new law impact my child’s mental health treatment?
Health plans can no longer place different treatment limitations on mental health care. In other words, the number of covered outpatient and inpatient mental health visits cannot be fewer than other medical outpatient/inpatient visits. Lifetime limitations must also be equal.
How will this impact my finances?
Co-pays, deductibles and out-of-pocket costs cannot be greater for mental health than physical health.
What about out-of-network benefits?
Out-of-network benefits for mental health services must also be the same as those for physical health. If a group health plan currently provides out-of-network benefits for only physical health, it must expand coverage to include out-of-network benefits for mental health starting January 2010.
What if I am denied benefits?
The reason for denial of service, reimbursement or payment has to be made available to you. Medical necessity is still in effect and may allow a health plan to deny your claim. Medical necessity criteria are available to anyone upon request and they are different for each health plan.
Who is my mental health insurance provider?
Probably not who you think it is. It is common practice for health plans to subcontract their mental health and substance use benefits to managed behavioral health care organizations. The benefits these subcontractors manage are referred to as “carve-outs.” Therefore, if you experience a problem with your mental health benefits, your primary insurance provider may refer you to the third-party subcontractor responsible for implementing that coverage.
What diagnoses are covered?
According to the new federal law, all mental and substance use disorders may be covered. However, the state of Texas requires that the following diagnoses be covered by mental health insurance:
- Bipolar Disorders
- Depression
- Major Depressive Disorders
- Obsessive-Compulsive Disorders
- Paranoid and Other Psychotic Disorders
- Schizoaffective Disorders
- Schizophrenia
- Pervasive Developmental Disorders (i.e. Autism)
It’s important to note that the federal law does not define mental illness and the different health plans are allowed to define the diagnoses they will cover in addition to the state’s requirements. Therefore, employer health plans can opt to drop coverage for a specific diagnosis not listed above.
Does the new law require my employer to provide mental health and substance use benefits?
No, employers do not have to include mental health and substance use benefits in their group health plans. The new law only applies to health plans that provide mental health and substance use benefits. Group health plans that include mental health and physical health benefits must provide equal coverage to both types of health care services. The majority of group health plans do include mental health coverage. Check with your employer’s human resources department to learn more about your employee health plan.
What does the new law NOT cover?
- The new law does not apply to individual health plans or group health plans with fewer than 50 employees.
- The new law does not apply to Medicare patients, however, it does apply to Medicaid managed care health plans.
- The new law does not require health insurance plans to provide mental health or substance use benefits.
About Southwest Mental Health Center
Southwest Mental Health Center (SMHC) is South Texas’ only nonprofit children’s hospital providing mental health care to children ages 3-17 years old. We provide a variety of services depending on the severity of a child’s mental health problems, ranging from outpatient to inpatient care. Our charitable care program enables us to provide greatly needed mental health care for children who could not otherwise afford to receive treatment.
Click here to download the PDF version of this flyer.
