Mental Health Parity and Addiction Coverage

What Is the Mental Health Parity and Addiction Equity Act?

The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers from imposing less favorable benefit limits on mental health or substance use disorder benefits than those applied to medical and surgical benefits. This principle is known as parity. The Centers for Medicare & Medicaid Services (CMS) explains that parity applies to financial requirements, such as deductibles and copayments, as well as to treatment limitations, like the number of visits allowed or the scope of services covered.

The law aims to ensure that coverage for behavioral health is not more restrictive or more costly than coverage for other health conditions.

How Does Parity Apply to Different Insurance Plans?

Parity rules apply broadly across many types of insurance. The Centers for Medicare & Medicaid Services (CMS) states that the law generally applies to most employer-sponsored group health plans and to individual and small-group plans sold on the Health Insurance Marketplace. For people covered under Medicaid or the Children's Health Insurance Program (CHIP), CMS notes that these programs have their own parity requirements, which ensure that behavioral health services are covered in a comparable way to other medical care.

Medicare also covers a range of mental health and substance use disorder services, including inpatient and outpatient care, as outlined by CMS. The U.S. Department of Labor (DOL) provides enforcement and guidance for many employer-sponsored plans and offers resources to help consumers understand their rights under these laws.

What Services Are Covered Under Parity?

Parity laws cover the benefits for mental health conditions and substance use disorders that a health plan offers. The Centers for Medicare & Medicaid Services (CMS) explains that parity applies to all benefits for such conditions, including outpatient care, inpatient treatment, counseling, and medication management. The specific services covered will depend on the individual plan, but the parity requirement means that any restrictions on these benefits—such as higher copays or fewer visits—must be no more restrictive than those placed on comparable medical and surgical benefits.

For Medicare, CMS notes that covered services include mental health and substance use disorder services provided by Medicare-enrolled providers and facilities.

What Should You Do If You Think Your Plan Is Not in Compliance?

If you believe your health plan is not following parity rules, the U.S. Department of Labor (DOL) suggests that you can contact your plan administrator or your state's insurance commissioner for assistance. The DOL also provides information and resources to help consumers understand their rights and file a complaint if needed.

The Centers for Medicare & Medicaid Services (CMS) notes that Marketplace plans must meet parity requirements, and consumers can also contact the Marketplace call center for help. For any emergency, you should call 911. If you are in crisis and need immediate support, you can call or text 988 to reach the 988 Suicide & Crisis Lifeline, as shared by SAMHSA.

Where Can You Find More Information and Help?

Official federal sources provide detailed information about mental health and substance use disorder coverage. The Centers for Medicare & Medicaid Services (CMS) has information on its website about parity requirements for Marketplace plans, Medicare, and Medicaid. The U.S.

Department of Labor (DOL) offers guidance and consumer resources on its website. SAMHSA provides a treatment locator tool online to help find substance use disorder services. For crisis support, SAMHSA also notes that the 988 Suicide & Crisis Lifeline is available 24/7 by calling or texting 988.

For medical emergencies, always call 911.

Questions to Ask a Qualified Professional

Because insurance plans and individual circumstances vary, it is important to speak with a qualified professional about your own situation. You may want to ask your insurance provider or a benefits administrator whether your specific plan is subject to federal parity laws and how your mental health or substance use disorder benefits compare to your medical and surgical benefits. A professional such as a healthcare provider or a patient advocate can also help you understand what services are covered under your plan and what steps to take if you encounter coverage issues.