Mental Health Symptoms

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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Mental Health

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


 Call 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.

#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:

(1) Outpatient services.

(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) *

(2) Schizoaffective disorder. ***  WedMD

(3) Bipolar disorder (manic-depressive illness).***  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 …

Mental Health Parity at a Crossroads

California Law Aims to Strengthen Access to Mental Health Services

Guide to #Contract Interpretation 

#Plain Meaning Rule
How to read a policy

How to read and figure out the law or Insurance Policy Provisions - Evidence of Coverage

  • Read the Statute – Policy
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  • Contract Interpretation in California: Plain Meaning, Parol Evidence and Use of the Just Result Principle
  • More on How to read a contract - Insurance Policy 


    The language of the text of the statute or  Evidence of Coverage EOC  should serve as the starting point for any inquiry into its meaning.    To properly understand and interpret a statute, [first] you must read the text closely, keeping in mind that your initial understanding of the text may not be the only plausible interpretation of the statute or even the correct one, per Justice Felix Frankfurter . Guide to Reading & Interpreting  *  American Society of Healthcare Risk Management    and * Wikipedia.

    The starting point in statutory construction is the language of the statute - Evidence of Coverage itself. The Supreme Court often recites the “plain meaning rule,”  as in, King vs Burwell Subsidies in Health Care.Gov upheld, that, if the language of the statute is clear, there is no need to look outside the statute to its legislative history in order to ascertain the statute’s meaning.

  • Parol Evidence Rule Wikipedia - Contract stands by itself - can't bring up discussions or agreements that were prior to actually signing the written Contract

  • The plain meaning of the contract will be followed where the words used—whether written or oral—have a clear and unambiguous meaning. Words are given their ordinary meaning; technical terms are given their technical meaning; and local, cultural, or Trade Usage of terms are recognized as applicable. The circumstances surrounding the formation of the contract are also admissible to aid in the interpretation.  West’s Encyclopedia of American Law,

  • A cardinal rule of construction is that a statute should be read as a

    Harmonious Whole,

    with its various parts being interpreted within their broader statutory context in a manner that furthers statutory purposes.  A provision that may seem ambiguous in isolation is often clarified by the remainder of the statutory scheme — because the same terminology is used elsewhere in a context that makes its meaning clear, or because only one of the permissible meanings produces a substantive effect that is compatible with the rest of the law.”

  • In Edgar v. MITE Corp., 457 U.S. 624 (1982), the Supreme Court ruled: “A state statute is void to the extent that it actually conflicts with a valid Federal statute.” In effect, this means that a State law will be found to violate the supremacy clause when either of the following two conditions (or both) exist:[3]

    1. Compliance with both the Federal and State laws is impossible, or
    2. “…state law stands as an obstacle to the accomplishment and execution of the full purposes and objectives of Congress…”

    Supreme Court - FINAL Ruling - Plain Meaning - No Jiggery Pokery 47 Pages, view our highlights, annotations & bookmarks

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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

Insurance Code 1374.72.   (a)

(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


Substance Abuse Treatment 


FEDERAL – Mental Health Parity and Addiction Equity Act of 2008

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

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

Resources & Links

  • Why insurers’ mental health coverage falls short Modern Health Care June 2003  
  • 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?


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2 comments on “Mental Health – ACA/Health Reform Mandated Essential Benefit

  1. 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?

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