Caretakers & Parents
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as an essential benefit under Health Care Reform
Every qualified health plan (ObamaCare compliant-meeting the 10 essential benefits) must provide parity coverage for mental health and substance use services resulting in no added treatment limits and no extra costs.
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NAMI (National Assoc of Mental Illness) Website, Insurance & Health Care Reform Section
More than 43 million Americans suffer from depression, anxiety, and other mental health conditions, according to the most recent federal data. 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. 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.
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Dealing with social & mental problems can cut health care costs CA Health Line 1.23.2017
Information, links and resources
May is Mental Health Awareness Month
Mental Health Parity Act 1996 Wikipedia
Parity – Using Employer Sponsored Plan SAMHSA 8 page pdf
- Medicare Billing Etc Guidelines for Professionals
- Our Webpage on Medicare & Mental Health
- Main Webpage on Mental Health
- Medicare.Gov on Mental Health
- Our webpage on EOC Evidence of Coverage - Plain English, even if they are 2 to 300 pages
- Los Angeles Times on low cost & free therapy alternatives
- NPR Mental Health & COVID
Mental Health Videos
- Mental Health Video - updates on Mental Health Parity - Mental Health must be covered the same as physical health
- Video Medicare-covered benefits for mental health.
- Sharp Health Care - Mental Health Videos - Play List
- Mental Health Insurance Coverage: Get the Whole Picture
- Veteran's Mental Health
- CMS Learning Aid for Mental Health Professionals
- See our Main Webpage on Mental Health
IMHO Easiest Place to verify Mental Health Benefits is in the EOC – Evidence of Coverage!
Individual – Specimen Platimum EOC – Evidence of Coverage – search for “mental”
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
- Employer Group Plans
- Medi-Cal HMO – Managed Care Providers
- Our Webpage on Evidence of Coverage
- Plain Meaning Rule - Plain Writing Act
- Our Webpage on OOP Out of Pocket Maximum - Many definitions are explained there.
Steve Explains how to read EOC
AB 88 Summary:
AB 88 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.
See below about mandate to cover Severe Mental Illness!
This bill also requires plans 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 *
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:
(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) 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 …
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. Blue Shield Summary & FAQ’s *
(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 in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders.
So, one must compare AB 88, with the
- 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
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.
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
.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
Mental Health Parity and Addiction Equity Act of 2008
Code of Federal Regulations §146.136 Parity in mental health and substance use disorder benefits.
May a plan impose other restrictions on mental health benefits?
Yes. Plans are still able to set the terms and conditions (such as cost-sharing and limits on the number of visits or days of coverage) for the amount, duration and scope of mental health benefits. http://www.dol.gov/
Resources & Links
§ 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:
Technical Links & Resources
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
BIC Benefits Identification Card
- Medi Cal Explained CHCF
- Historical Guide 2006 CHCF 174 pages
- Cal AIM California Advancing and Innovating Medi-Cal — is a far-reaching, multiyear plan to transform California’s Medi-Cal program and to make it integrate more seamlessly with other social services. The goal of CalAIM is to improve outcomes for the millions of Californians covered by Medi-Cal, especially those with the most complex needs.
- Medi Cal Contact Information
- 10 Essential Health Benefits
- Our Webpage on Medi & Denti Cal Benefits
- Western #Poverty Law - Exact Legal Rules on Coverage for Low Income Californian's