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Mental health or substance use care denied: parity and appeals

Federal law says that if a plan covers mental health or substance use disorder care, it generally has to treat that care comparably to medical and surgical care. A denial is not always a parity problem, but you can appeal either way.

What parity means

According to the Department of Labor, the Mental Health Parity and Addiction Equity Act does not force a plan to cover mental health services. If a plan does cover them, copayments, visit limits and other limits cannot be tougher than those for comparable medical or surgical care. The Department describes this for employer group plans (insured and self-funded), individual and small-group plans bought through the Marketplace, some Medicaid plans including managed care, and CHIP. It says parity does not apply to retiree-only plans, Medicare plans, church-sponsored plans or certain small employer plans.

Red flags the Department of Labor lists

• Pre-approval or repeated re-approval required for all mental health benefits (for example, only a few days approved at a time).
• A network of mental health providers that is much thinner than the network for medical providers.
• Pre-approval every 3 months for medications that treat mental health conditions.
• Refusing coverage because you did not finish earlier treatment, or because there is "no likelihood of improvement."
• Requiring an updated treatment plan every 6 months or coverage stops.

The Department says that if you see one of these, the plan may be breaking parity rules, and suggests calling its Benefits Advisors (see below).

Steps if care or a claim was denied

1. Get the rules in writing. Ask the plan for its Summary Plan Description or Summary of Benefits and Coverage, and for the information it used to decide the denial, including any pre-approval or medical necessity rules. The Department says plans must give copies of the information they use for these decisions within 30 days of your request. The claim file request letter can help.
2. Appeal in writing. Employer plans usually give you 180 days from the plan's decision to appeal, and generally must answer within 60 days of the appeal. Use the internal appeal letter or, for a doctor-ordered treatment, the medical necessity appeal. If waiting could seriously harm your health, ask for an expedited review.
3. Ask for external review if the plan still says no. For most plans you can ask for an independent external review after finishing the plan's internal appeals. The Department says to request it within 4 months of the final denial, and that the reviewer should decide within 45 days. See external review and the external review request letter.
4. Call for help. Employer-plan members can call an EBSA Benefits Advisor at 1-866-444-3272 (free). The Department also lists a U.S. Department of Health and Human Services line, 1-888-393-2789 (leave a message). For plans bought through a state-regulated insurer, your state insurance department may also take complaints.

Denials that may not be parity violations

The Department says a denial does not automatically break parity rules if the service is not medically necessary, no longer fits the setting or level of care (for example, residential treatment no longer being necessary so only outpatient visits are paid), is considered experimental, or is not a covered benefit. You can still appeal these, and your doctor's letter can matter.

Not legal or medical advice. Parity rules are technical; the Department of Labor page above is the place to read them. This site does not review your plan or tell you whether a violation occurred.

Related guides

• Health insurance denial: first steps
• How to file a health insurance internal appeal
• Independent external review: how it works
• ERISA vs state-regulated health plans: why it matters
• State insurance department directory