Mental Health and Substance Use Disorder Health Insurance Coverage Parity
If you have mental health or substance use disorder needs, the last thing you want to hear is that your health insurance plan doesn’t cover the services you need or there is no provider available to help you.
Unfortunately, many New Yorkers struggle with finding providers in their health insurance plan’s network, dealing with premiums and co-pays, and getting their benefits covered, which can put them at risk of not getting needed life-saving care.
New York State (NYS) is overseeing and enforcing parity laws to make sure mental health and substance use disorder services can be readily accessed by the people who need them, when they need them.
Federal Parity Laws
The major federal laws that protect your rights to get equal access to your mental health and substance use disorder benefits are:
- the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008; and
- the Patient Protection and Affordable Care Act of 2010.
These laws apply to most health insurance plans.
New York State Parity Laws
NYS also has laws that enhance coverage and promote access to behavioral health services, including:
- Timothy’s Law of 2006; and
- the NYS Mental Health and Substance Use Disorder Parity Reporting Act of 2018.
NYS laws only apply to insurance products regulated by NYS. NYS-regulated Plans are listed on the Department of Financial Services website:
What do These Laws Do?
It is important to know that, in combination, these New York State and federal laws require most comprehensive health insurance plans to cover medically necessary mental health services and manage your mental health or substance use benefits as they manage medical and surgical benefits, without additional limitations.
This means that insurance plans are forbidden to require you to “fail first” at a lower level of care before they cover treatment recommended by your doctor or therapist, such as inpatient hospitalization.
NYS Regulation of Medical Necessity Criteria
Medical Necessity Criteria for NYS Regulated Health Insurance Plans
When conducting utilization review of mental health services, health insurance plans regulated by New York State, including Medicaid Managed Care plans, must use medical necessity criteria and level of care tools that are:
- evidenced based;
- peer reviewed;
- age appropriate; and
- approved by the Office of Mental Health.
The Office of Mental Health has developed guiding principles for this review and approval, which are available here:
Notification for Health Insurance Plan Members
Health insurance plan members in New York State are entitled to request and receive copies of the medical necessity criteria used by health plans to make determinations regarding behavioral health benefits.
If a service is denied, any denial notice must include:
- the specific reason for the denial;
- the relevant denial code;
- the meaning of the denial code; and
- a description of the standards used in denying the claim, with a reference to the specific plan provisions relied upon.
For denials based on medical necessity determinations, the health insurance plan must also provide an explanation of the scientific or clinical judgment used to make the decision, applying the terms of the health insurance plan to the specific medical circumstances in your case.
You or your provider can request this information from your health insurance plan using the form letters from the Parity Enforcement Project Initiative.
Health plan members are also entitled to request and receive a copy of the most recent comparative analysis performed by their health insurance plan to assess compliance with federal parity laws and regulations. If your health insurance plan refuses to provide this information to you, contact the Consumer Assistance Unit of the NYS Department of Financial Services at 1-800-342-3736.
Authorizing Inpatient Psychiatric Stays for Children and Youth (Under Age 18)
NYS law now prohibits NYS-regulated health insurance plans from requiring preauthorization, or from performing concurrent review, during the first 14 days of an inpatient admission for the treatment of a mental health condition of an individual under the age of 18.
This law applies when a child or youth under the age of 18 is admitted to a psychiatric inpatient unit at an OMH-licensed facility that is part of their health insurance plan’s provider network. The facility has to notify the health insurance plan about the admission and treatment plan within two business days, but does not need to request prior authorization before providing treatment. The facility should continue to work with the health insurance plan to provide needed care.
Under this law, it is the responsibility of the inpatient hospital provider to make sure all care provided and billed for is medically necessary. If the health insurance plan later determines the care was not medically necessary, you will not have any financial obligation to your healthcare provider for the treatment other than any copayment, coinsurance, or deductible otherwise required under your policy.
The Office of Mental Health has developed guidance for health insurance plans and hospitals that provide inpatient mental health care for individuals under the age of 18.
Template Notification Form and Initial Treatment Plans:
Reports and Oversight
NYS Mental Health Parity and Addiction Equity Act Report - April 2019
The NYS Department of Health, Office of Mental Health, and Office of Alcoholism and Substance Abuse Services reviewed Medicaid Managed Care Plans, Alternative Benefit Plans, and Children’s Health Insurance Program (CHIP) Plans for mental health and substance use treatment benefit coverage.
NYS Mental Health Parity Report - May 2018
Report from the NYS Office of the Attorney General stemming from an industry-wide investigation of health plans’ compliance with state and federal mental health and addiction parity laws.
To report a disparity in mental health and or/substance use disorder benefits, please contact:
New York Department of Financial Services Online Complaint Form
Consumer Assistance Unit: 1-800-342-3736
New York Department of Health
New York Attorney General Health Care Bureau Online Complaint Form
If you have any questions about Mental Health Parity in NYS, you can email OMH-Parity@omh.ny.gov.