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How to overturn managed care treatment denials
State mental health parity insurance laws only apply to privately insured plans offered through an employer. Parity means that equal coverage (deductibles, co-payments, visit limits, annual spending limits, and lifetime limits) is provided for treatment of mental health conditions as is provided for treatment of other health conditions.
Mental Health Parity laws vary significantly from state to state. The Center for Mental Health Services Report on State Parity Laws at http://store.samhsa.gov/product/SMA07-4228 provides state-specific information about mental health parity. There is a chart (pages 16-44) that offers a brief summary of the mental health parity law for each state to help you better understand your state's parity law.
In addition, there are some important exceptions to keep in mind in reviewing what parity protections may apply. These include the following:
If you live in one state but work for a company whose headquarters is in a different state, your insurance coverage will be determined by the state laws in the state in which your company's headquarters is located.
- If you work for a small business, your employer may not have to follow your state's parity laws (see page 40 in above report)
- If you work for a large company that is self-insured, only federal regulations apply. Unfortunately, federal requirements are very weak, and only require equal lifetime and annual spending limits, but not equal deductibles, co-payments, or visit limits. To find out more about the Federal Parity law, the Mental Health Parity Act of 1996, visit www.cms.hhs.gov/HealthInsReformforConsume/04_TheMentalHealthParityAct.asp.
Federal parity legislation was passed in October 2008 that will offer more consistent protections across state lines. To find out more about this, visit Mental Health America's information on parity http://takeaction.mentalhealthamerica.net/site/PageServer?pagename=Equity_Campaign_parity_legislation.
The information we are providing is designed to help you better understand your mental health insurance benefits. By knowing what questions to ask and what state laws apply in your situation, you will have a better chance of getting the services you and your family need. Health insurance policies can be very complicated, but don't let a lack of understanding about what's covered stop you from seeking help.
Options for obtaining public and private insurance vary from state to state depending on state laws governing insurance regulation. You may qualify for insurance under the Affordable Care Act.
The Center for Consumer Health Choices, Consumers Union guidebook "A Consumer Guide to Handling Disputes with your Employer or Private Health Plan" includes a section that lists which states offer external appeals. This information would be helpful should your insurance company repeatedly deny a claim. For more information on appealing treatment denials, see Mental Health America's FAQ "What can I do if my insurance company is refusing to approve claims for mental health treatment?"
If you need additional help understanding your health insurance policy, mental health parity laws in your state and how they apply to your specific situation, have questions about a treatment denial, or need information about any other protections that may be available in your state, you can contact your state Department of Insurance or State Insurance Commissioner's consumer hotline.