We are committed to educating consumers about your rights and opportunities under health care reforms such as the Mental Health Parity law and the Affordable Care Act. The tools and resources provided here can assist you in understanding your insurance plan and accessing health insurance coverage for substance use disorder and mental health treatment. Parity Toolkit for Addiction and Mental Health Consumers, Providers and Advocates This comprehensive toolkit is designed to inform and assist you—as well as your family, care providers and recovery advocates—in accessing addiction treatment, and understanding your rights and benefits under the Mental Health Parity Act. Use these materials to help you: Communicate with your health insurance company about coverage under your insurance plan Prepare and document information should disputes arise over coverage or reimbursement Understand your rights to appeal as well as appeal procedures Download the Addiction and Mental Health Parity Toolkit. Insurance Coverage for Addiction and Mental Health: Now It Is the Law This pamphlet will help you ask the right questions when working with your insurance company. It also provides a glossary to help you decipher terms and language related to health insurance coverage for mental health and addiction treatment. Download Now It Is the Law pamphlet. Patient Request for Reasonable Denial Use this letter template to request the reason for denial of addiction treatment coverage from your insurance company. Download the Patient Reasonable Denial template. Doctor/Provider Request for Reasonable Denial This letter template may be completed by your doctor/provider to request the reason for denial of addiction care coverage from your insurance company. Download the Doctor/Provider Reasonable Denial template. Your Parity Rights: Details on the Law Benefit Classification Parity is determined on a classification basis. Thus if an insurance plan offers medical/surgical benefits in one classification, it must also provide on-par mental health/addiction treatment (MH/SA) benefits in that classification. The six classifications are: Inpatient/in-network Inpatient/out-of-network Outpatient/in-network Outpatient/out-of-network Prescription drugs Emergency Quantitative Parity Benefits Quantitative benefits are those that can be measured easily. If an insurance company is not offering parity between quantitative benefits, it is usually easy to address. Some examples of quantitative benefits that are addressed by parity legislation are: Lifetime or annual dollar limits imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits. Financial requirements (e.g., deductibles, co-payments, coinsurance, out-of-pocket expenses) imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits. Treatment limitations (e.g., frequency of treatment, number of visits, number of days, or similar limits on scope or duration of treatment) imposed on MH/SA benefits may NOT be more restrictive than those imposed on medical/surgical benefits. There can be NO separate cost-sharing requirements or treatment limitations that are applicable only to MH/SA benefits. Non-quantitative Treatment Limitations In addition to the financial requirements and treatment limits, there are limits on the scope or duration of mental health and substance use disorder treatment that are not so easily quantified. These non-quantitative treatment limits for MH/SA must be comparable to medical/surgical benefits: Medical management standards Use of fail-first or step therapy protocols Use of failure to complete a course of treatment Methods for determining usual, customary and reasonable charges Additional Protections There are a few additional protections offered through parity legislation. Medical Necessity Determination and Disclosure Criteria for medical necessity determinations and the reason for any denial must be made available to contracted providers, or to the plan participant or beneficiary upon request. Thus, plans can no longer take the position that medical necessity criteria or specific reasons for denial are "proprietary" or can otherwise be withheld. Please be sure to make your request in writing, and seek a prompt/immediate response. Where there is a state parity law or state mandate, the federal Mental Health Parity law serves as the floor and state laws must be enhanced to reach the federal floor. Combined Deductibles and Out-of-Pocket Maximums Deductibles and out-of-pocket maxes are to be combined for both medical/surgical and MH/SA benefits. (Annual and lifetime limits must be equal, but may be maintained separately). Be certain that plans are not quoting or applying separate deductibles or out-of-pocket maxes.