Employer Health Insurance Parity
There are several different coverage options an employee might get through their employer, and there are differences in coverage requirements but the main thing to know when it comes to parity is - if your employer is based in Pennsylvania and your employer-sponsored insurance covers mental health and substance use disorder treatment benefits, then your health insurance plan cannot impose less favorable benefit limitations on mental health and substance use disorder benefits than on physical health benefits.
This means your benefits must be the same in terms of:
- What you pay: Co-pays, co-insurance, deductibles, and out-of-pocket maximums
- How much treatment you can get: Limitations on services utilization, such as limits on the number of inpatient days or outpatient visits that are covered
- The use of management tools, such as prior authorization requirements
- Which doctors you can see, and your coverage for out-of-network providers
- The criteria and process the insurance company uses to determine what is considered medically necessary treatment.
If you have questions about any of the information here or about parity laws, visit the Pennsylvania Insurance Department's Consumer Services Bureau online or call their hotline at 1-877-881-6388.
Coverage Requirements By Employer Plan Type
The laws pertaining to coverage of mental health and substance use disorder services depends upon the type of employer health insurance plan you have so, let's determine what type of employer coverage you have so we can provide you with some specifics.
-
Self-Insured Employer Plan - The plan is administered by a third party and the employer pays health care service claims themselves
-
Fully-Insured Small Business Employer Plan - An employer with 50 or fewer employees purchases coverage from a health insurance company for its employees
-
Fully-Insured Large Business Employer Plan - An employer with 51 or more employees purchases coverage from a health insurance company for its employees
-
Fully-Insured Employer Based in Another State - An employer purchases coverage from a health insurance company for its employees BUT is not based in Pennsylvania
start of self-insured employer
|
Self-Insured Employer Plan | |
|---|---|
|
What is it? |
A self-insured employer plan will use a third party to administer their health insurance but pay claims for health care services themselves.
It can be difficult to tell if your employer self-insures or is fully insured so if you aren't sure, contact your human resources department, benefits manager, or the person in management that handles insurance, and they can tell you. |
What's Covered? | Check with your human resources department to determine what benefits are covered by your health insurance plan.
Self-insured employer plans are not required to cover any specific mental health and substance use disorder benefits, but many do provide these benefits. And, if they do provide mental health and substance use disorder treatment benefits, they cannot impose less favorable benefit limitations on mental health and substance use disorder benefits than on physical health benefits. |
| Where Do I Go for Help? |
These plans are not regulated by the Pennsylvania Insurance Department so if you think your insurance company is making it more difficult for you to access behavioral health services than physical health services, contact:
|
|
More Information |
|
start of small-business employer
|
Fully-Insured Small Business Employer Plan | |
|---|---|
|
What is it? |
Health insurance provided by a small employer (50 or fewer employees) |
|
What's Covered? | Most small group health plans are required to cover mental health and substance use disorder services, including behavioral health services. Pennsylvania sets a minimum amount of services that must be covered within each of these categories. For example, for plans that begin on or after January 1, 2017, all small-group health insurance plans in Pennsylvania must cover:
These plans must also cover certain types of drugs, including anti-depressants, mood stabilizers, and drug treatments for opioid dependence. They do not have to cover every possible drug in each of these categories. Pennsylvania law also requires small group plans to cover minimum levels of benefits for alcohol and substance use treatment:
The benefits identified above must be covered without the day, admission, or session limits identified above, though anything above these benefit levels may be subject to medical management like prior authorization or medical necessity review.
Your insurance company can still put reasonable limits on these benefits, such as only covering services performed by an in-network provider or only covering services if they are medically necessary, but it is critical to know that your health insurance company cannot impose less favorable benefit limitations on mental health and substance use disorder benefits than on physical health benefits. |
| Where Do I Go for Help? | If you think your insurance company is making it
more difficult for you to access behavioral health services than physical
health services in any way or have questions about this requirement, reach out to our Consumer Services Bureau for help. |
|
More Information |
|
start of large-business employer
|
Fully-Insured Large Business Employer Plan | |
|---|---|
|
What is it? | Health insurance provided by a large employer (51 or more employees) where an employer purchases coverage from a health insurance company for a set premium and the health insurance company pays all the claims for health care services. |
What's Covered? | Pennsylvania law requires large group insurance to cover certain serious mental illnesses as well as minimum levels of benefits for alcohol and substance use treatment. Many large group policies provide additional and more comprehensive benefits for mental health and substance use disorder treatment, but they are not required to do so. Check with your insurance provider or your human resources department to learn more about what benefits are covered by your health insurance plan. The minimum required benefits for alcohol and substance use treatment are listed here, but your insurance plan may be required to cover more than these minimum benefits, as we will explain next. (The insurance company may use medical management techniques, like prior authorization or medical necessity reviews, above these minimum benefit levels.) The minimum benefits are:
Whether your insurance company only covers these required benefits or additional mental health and substance use disorder benefits, your health insurance plan cannot impose less favorable benefit limitations on mental health and substance use disorder benefits than on physical health benefits.
As one specific example, we talked earlier about the minimum benefits for alcohol and substance use treatment required by Pennsylvania law. Your insurance company can only use the minimum limits we listed above if they use the same limits for equivalent physical health services. If their limits for alcohol and substance use treatment are lower, the insurance company likely would be violating the parity law. If your insurance plan has more generous benefits (such as no limits) on a given physical health service, they must offer those same generous benefits for corresponding behavioral health and substance use disorder services. |
| Where Do I Go for Help? | If you think your insurance company is making it
more difficult for you to access behavioral health services than physical
health services in any way or have questions about this requirement, reach out to our Consumer Services Bureau for help. |
|
More Information |
|
start of out-of-state employer
|
Fully-Insured Employer Based in Another State | |
|---|---|
|
What is it? |
An employer who purchases coverage from a health insurance company for a set premium and the health insurance company pays all the claims for health care services
BUT is not based in Pennsylvania. |
What's Covered? |
Pennsylvania parity laws only apply to employers based in Pennsylvania. |
| Where Do I Go for Help? | If you live in Pennsylvania, but work for an employer based in another state, you should contact that state’s insurance department. |
Red Flags
It can be difficult to know if your health insurance company is following parity laws, so if you feel they may not be, look for these red flags:
- A higher co-pay for behavioral health services than you have for physical health services
- 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
- A requirement to ask your insurance company for permission (called prior authorization) to access behavioral health services, but not for physical health services
- Seeing an out-of-network doctor for physical services, but not behavioral health services
- Your insurance company says it will not pay for behavioral health services your doctor says you need
- Your insurance company making you try outpatient behavioral health services before it will pay for inpatient behavioral health care
- Your insurance company refuses to pay for substance use disorder treatment in a residential treatment facility because they said it wasn't "medically necessary"
These aren't the only warning signs for possible violations of this law, but these are obvious red flags you can look for.
Get Help
If you have questions about parity that aren't answered here or if you aren't sure where to start, visit the Pennsylvania Insurance Department's Consumer Services Bureau online or call their hotline at 1-877-881-6388.