Mental Health as an essential benefit under ACA Health Care Reform
Parity Laws – Mental Health must be equal to Medical Benefits
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is an essential mandated benefit under ACA/ObamaCare/Health Care Reform
All Insurance plans – qualified health plan (Obama Care compliant-meeting the 10 essential benefits) must provide parity – equal coverage for mental health and substance use services resulting in no added treatment limits and no extra costs.
More than 43 million Americans suffer from depression, anxiety, and other mental health conditions. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care, like Narrow Provider Lists? Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.
Hopefully, the ACA mandate and parity laws will help remedy the problem.
Information, links and resources
- Mental Health Parity Act 1996 Wikipedia
- Parity – Using Employer Sponsored Plan SAMHSA 8 page pdf
- I’m not sick & don’t need help – Book
- Dealing with social & mental problems can cut health care costs CA Health Line 1.23.2017
- NAMI (National Assoc of Mental Illness) Website, Insurance & Health Care Reform Section
- FAQ on if Mental Health Therapist Benefits vary by Metal Level
- Our Webpages on:
- Medical Necessity Webpage
- EOC Evidence of Coverage Value and how to find
- Resources – Mental Health – Conservatorship – FSP
- Medicare and other resources on Mental Health
- Appeal & Grievances? Medicare – Medi Cal – Covered CA
- Privacy – Federal HIPAA
- Fraud, Scams, Waste & Abuse Risk Adjustment
- Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million Americans, that details how EHBs will expand mental health and substance use disorder benefits and federal laws requiring that mental health benefits be equal to, or have “parity” with, other health benefits in the individual and small group markets. .bna.com/hhs-releases-essential-n17179872551/
- Medi Cal & Behavioral Health Services
- health payer intelligence.com private-insurance-covers-most-nonelderly-adults-with-mental-health-needs
988 for Mental Health Emergencies
Mid July 2022 there is supposed to be a new # to call, just like 911 for Mental Health Emergencies, but the funding doesn't see to be there for California.
#Medicare & You - Mental Health
- Medicare & Mental Illness Publication # 10184
- Find therapists who accept Medicare Assignment
- Medicare Billing Etc Guidelines for Professionals
- Our Webpage on Medicare & Mental Health
- Mental Health
- Medicare.Gov on Mental Health
- EOC Evidence of Coverage - Plain English,
- Los Angeles Consumer Resources #Directory
- Los Angeles Times on low cost & free therapy alternatives
- NPR Mental Health & COVID
- Guide to Mental Health Benefits (The Mighty)
- Compliance Assistance Guide from DOL.Gov Health Benefits under Federal Law
- Mental Health Videos
- Veteran's Mental Health
- CMS Learning Aid for Mental Health Professionals
#California Mental Health Insurance Parity
AB 88 CA Insurance Code §§10144.5. Health and Safety Code§1374.72 requrires that severe mental illness for children be covered and also prohibits health plans from basing medical necessity denials on whether the admission for mental health services was voluntary or involuntary, WIC 5150 hold CA Legislator * or on the method of transportation of the patient to the health facility.
AB 88 also requires Insurance Companies that offer mental health services (Individual & Families * Medi-Cal * Employer Groups) to have information on their website that will assist enrollees in accessing mental health services. SB 1553 §1368.015, §1367.015Health & Safety Code Blue Cross / Anthem Mental Health Procedures
SB 221 Return Visit Guarantees
SB 221 requires that Mental health and substance abuse patients be offered return appointments no more than 10 days after a previous session, unless their provider OKs less frequent visits. CA HealthLine * CA Health Line 11.24.2021 *
Severe Mental Illness Coverage
AB 88 – Insurance Code §10144.5
(a) Every policy of disability (health) insurance that covers hospital, medical, or surgical expenses in this state* … shall provide coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child, … under the same terms and conditions applied to other medical conditions,
(b) These benefits shall include the following:
(2) Inpatient hospital services.
(3) Partial hospital services.
(4) Prescription drugs, if the policy or contract includes coverage for prescription drugs.
How to obtain, get or find these benefits?
(c) The terms and conditions applied to the benefits required by this section that shall be applied equally to all benefits under the disability (Health, Medical) insurance policy shall include, but not be limited to, the following:
(1) Maximum lifetime benefits.
(2) Co-payments and coinsurance.
(3) Individual and family deductibles.
(d) For the purposes of this section, “severe mental illnesses” shall include [these diagnosis]:
(1) Schizophrenia schizophrenia.com/ *** WebMD
(2) Schizoaffective disorder. *** WedMD
(3) Bipolar disorder (manic-depressive illness). bipolar.com/*** WebMD
(4) Major depressive disorders. *** WebMD
(5) Panic disorder. *** WebMD
(6) Obsessive-compulsive disorder.*** WebMD
(7) Pervasive developmental disorder WebMD or autism. *** Web MD
(8) Anorexia nervosa. *** WebMD
(9) Bulimia nervosa. *** WebMD
(e) For the purposes of this section, a child suffering from, “serious emotional disturbances of a child” shall be defined as a child who
(1) has one or more mental disorders as identified in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms, and …
California Law Aims to Strengthen Access to Mental Health Services
SB 855 2020
#Substance Abuse Treatment
SB 855 requires insurance companies to expand the definition of Mental Health to include Substance abuse and cover as any other illness. Learn More — Bill Summary
(2) “mental health and substance use disorders” means a mental health condition or substance use disorder that falls under any of the diagnostic categories listed … Diagnostic and Statistical Manual of Mental Disorders.
(g) This section shall not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies. Autism 7.1.2012 SB 946 §10144.5.
Plans must cover out-of-network services based on billed charges (rather than a discounted allowed amount or negotiated price) immediately if the plan was not able to provide in-network services in a timely manner based geographic access and timeliness requirements. CA Health Line *
Links & Resources
- Blue Shield Summary & FAQ’s *
- CA Insurance Commissioner letter to All Health Insurance Companies to comply with SB 855 to provide coverage for medically necessary treatment of mental health and substance use disorders, as defined, under the same terms and conditions applied to other medical conditions.
- magellan provider focus.com/what-you-need-to-know-about-senate-bill-855
- Analysis of California Senate Bill 855 Health Coverage: Mental Health or Substance Abuse Disorders 104 pages report to State Legislature
- Treatment Guidelines: Substance Use Disorders
- PRACTICE GUIDELINE FOR THE Treatment of Patients With Substance Use Disorders Psychiatry Online . org 276 pages
- Magellan’s Adopted Clinical Practice Guidelines For the Assessment and Treatment of Patients With Substance Use Disorders
- Fact Sheet SB 855 5 pages Senator Scott Wiener
Guide to #Contract Interpretation
- Read the Statute – Policy
- Read the Statute – Policy
- Read the Statute – Policy
- Then when you think you understand it, read it again
- Plain Language Video
- Tools to Read a Statute VIDEO
- Contract Interpretation in California: Plain Meaning, Parol Evidence and Use of the Just Result Principle
Our webpage on
- jiggery pokery and contract interpretation
- Evidence of Coverage EOC
- Plain Meaning Rule - How to read Policy - Contract
Quotit - #Find Provider - ALL Companies
How to see MD list when using our quote engine
FEDERAL – Mental Health Parity and Addiction Equity Act of 2008
- Fact Sheets & FAQs
- Regulations & Guidance
- United loses in court on behavioral health coverage rules Modern Health Care 3.5.2019
- Code of Federal Regulations §146.136 Parity in mental health and substance use disorder benefits.
Mental Health Bill of Rights
The Mental Health Parity Act of 1996 (MHPA)
MHPA is a federal law that may prevent your group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower – less favorable – than annual or lifetime dollar limits for medical and surgical benefits offered under the plan. Learn more on Wikipedia Mental Health Parity Act 1996
The act removes separate treatment limitations for mental health and chemical dependency benefits (including number of visits, days of coverage, and annual dollar limits) and requires cost sharing for these services to be equal to or less than the cost sharing for other health care services. (Federal Mental Health Parity Act of 2007 NAMI More on Mental Health Parity NAMI) Public Law 110–343 wikipedia.org/110-343
MHPA applies to most group health plans with more than 50 workers. MHPA does NOT apply to group health plans sponsored by employers with fewer than 51 workers. MHPA also does NOT apply to health insurance coverage in the individual market.
MHPA is a federal law that requires that annual or lifetime dollar limits on mental health benefits provided by a group health plan be no lower than the annual or lifetime dollar limits for medical and surgical benefits offered by that plan. MHPA applies to employers with more than 50 employees. For up to date information on the applicability of the Mental Health Parity Act, contact the EBSA regional office nearest you.
- Statute1185 A
- Fact Sheet
The MHPA does not prohibit group health plans from:
Covering mental health services within network only, even though the plan will pay for out of network services for
- medical/surgical benefits (although with higher out-of-pocket cost to the subscriber);
- Increasing co-payments or limiting the number of visits for mental health benefits;
- Imposing limits on the number of covered visits, even if the plan does not impose similar visit limits for medical and surgical benefits; and
- Having different cost-sharing arrangements, such as higher coinsurance payments for mental health benefits, as compared to medical and surgical benefits
- HOWEVER, check out the rules under ACA/Obamacare & AB 88
.A visit limit coupled with a usual, customary, and reasonable (UCR) charge is not the equivalent of an annual or lifetime dollar limit. As a result, it is not a violation of the MHPA requirements. Payments made by the plan on the basis of UCR charges will vary from one case to the next.
What is not permitted is a limit on the number of visits, together with a fixed dollar limit per visit, for example, 60 visits annually at $50 per visit (totaling $3,000), unless the medical-surgical coverage is the same.cms.hhs.gov
Resources & Links
- Technical Resources
- § 146.136 Parity in mental health and substance use disorder benefits. Federal Code of Regulations
- IRS Code § 9812. Parity in the application of certain limits to mental health benefits
- Federal MHPA Renewal Legislation S.558
- Go to the Library of Congress and put this information in their search screen, to learn more about any pending legislation:
- 42 USC 18022 (E) Mental health and substance use disorder services, including behavioral health treatment.
- CFR 156.115 (a) (3), – Federal Provisions of Essential Health Benefits
- §146.136 Parity in mental health and substance use disorder benefits.
- NAMI Website
Maximum #a190 Medicare Psychiatric Inpatient Days?
- If one is mentally #ill, has Medicare and Medi Cal, is constantly in and out of inpatient care, will Medi Cal pay if Medicare doesn’t as the person maxed out his inpatient days and used up the lifetime limit?
- Yes, Medicare pays or doesn’t pay and then Medi Cal is the secondary payer. § 1300.67.13. Coordination of Benefits (“COB”).
- References & Links
- Our webpages on:
- What is covered under Medicare Parts A & B
- Appeals & Grievances
- Dual Coverage
- Which Pays first Medi Cal or other coverage?
- Medicare #DualCoverage
- most health care costs are covered if you qualify for both Medicare and Medicaid. Medicaid never pays first for services Medicare covers. It only pays after Medicare has paid Page 11
- Choose Medi Cal HMO
- Medicare #DualCoverage
- SSI, SSDI & Automatic Medicare Coverage
Medicare Benefit Period – CA Health Care Advocates
Medicare & You Publication 10050 Page # 121
The way that Original Medicare measures your use of hospital and skilled nursing facility services. A benefit period begins the day you’re admitted as an inpatient in a hospital or skilled nursing facility. The benefit period ends when you haven’t gotten any inpatient hospital care (or skilled care in a skilled nursing facility) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.
Mental health care (inpatient) Medicare.Gov Medicare & You page 27
However, if you’re in a psychiatric hospital (instead of a general hospital), Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.
- Try Medi Cal for additional days
LA Care EOC Evidence of Coverage and Member Handbook
Coordination of Benefits (COB): The process of determining which insurance coverage (Medi-Cal, Medicare, commercial insurance or other) has primary treatment and payment responsibilities for members with more than one type of health insurance coverage.
The LA Care EOC page 49 states:
Other Medi-Cal programs and services
Other services you can get through Fee-For-Service (FFS) Medi-Cal or other Medi-Cal programs
Sometimes L.A. Care does not cover services, but you can still get them through FFS Medi-Cal or other Medi-Cal programs. This section lists these services. To learn more, call L.A. Care Member Services at 1-888-839-9909 (TTY/TDD 711).
- Medi Cal coverage – County Mental Health
Specialty mental health services
Some mental health services are provided by county mental health plans instead of L.A. Care. These include specialty mental health services (SMHS) for Medi-Cal members who meet medical necessity rules. SMHS may include these outpatient, residential and inpatient services:
• Inpatient services:
° Acute psychiatric inpatient hospital services
° Psychiatric inpatient hospital professional services
° Psychiatric health facility services
To learn more about specialty mental health services the county mental health plan provides, you can call your county mental health plan.
To find all counties’ toll-free telephone numbers online, visit dhcs.ca.govMHPContact List
- Medi-Cal Specialty Mental Health Services
- Medi Cal and Social Service Contacts for Assistance
- Evidence of Coverage D SNP – Page 77
- CBO.gov THE INPATIENT PSYCHIATRIC HOSPITAL BENEFIT UNDER MEDICARE July 1993
- Medi Cal Inpatient Mental Health Services Program
- chcf.org/Medi Cal Explained Behavioral Health.pdf
- ‘Go on Medi-Cal to get that’: Why Californians with mental illness are dropping private insurance to get taxpayer-funded treatment
- Advocates Guide to Medi Cal – Mental Health
- Cal. Code Regs. Tit. 9, § 1820.205 – Medical Necessity Criteria for Reimbursement of Psychiatric Inpatient Hospital Services
- MHSUDS INFORMATION NOTICE NO.: 19-026
AA’s 12 STEPS, INCLUDING #POWERFUL 4 TH STEP WORKSHEETS
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How to get the Health Care
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- Medi Cal Explained CHCF
- More explanation
- California Advancing and Innovating Medi-Cal (CalAIM) is a long-term commitment to transform and strengthen Medi-Cal, offering Californians a more equitable, coordinated, and person-centered approach to maximizing their health and life trajectory.
- Medi Cal Contact Information
- Our Webpages on
- Medi Cal Benefits
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- Medi-Cal – MAGI Income Eligibility Criteria
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- Full Scope Medi-Cal – Benefits & Coverages
- Transitions from Medi-Cal to get Covered CA
BIC Benefits Identification Card
Mental Health - Related Pages
- 10 Essential Mandatory Federal Benefits ACA + CA Benefits
- Mental Health – ACA/Health Reform Mandated Essential Benefit
- Mental Health – Outpatient – Therapist – Medicare
- Resources – Mental Health – Conservatorship – FSP
- Find Resources – Aunt Bertha
- FSP Full Service Partnership
- Laura’s Law
- Lanterman LPS Conservatorships
- Gravely Disabled Definition
- Consumer Guide to LPS Act
- Probate Conservatorships
- Power of Attorney
- Special Needs Trust
- §1370 Murphy Conservatorship
- Social Determinants of Health Togetherness – Loneliness
- Organizing, Hoarding, & Cluttering
- Medicare & Mental Health
- Pre-Existing Conditions – ACA No more!
Specimen Individual Policy #EOC with Definitions
Employer Group Sample Policy
It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc! Plus, EOC's are mandated to be written in PLAIN ENGLISH!
- Find your own Individual EOC Evidence of Coverage
- It' important to use YOUR EOC not just stuff in general!
- Obligation to READ your EOC
- Plain Meaning Rule - Plain Writing Act
- Our Webpage on Evidence of Coverage
- OOP Out of Pocket Maximum - Many definitions are explained there.
If one is mentally ill, has Medicare and Medi Cal, is constantly in and out of inpatient care, will Medi Cal pay if Medicare doesn’t as the person maxed out his inpatient days and used up the lifetime limit?
We are answering your question in the webpage above.