Editor’s Note: This information is adapted from the Substance Abuse and Mental Health Service’s Guide, “Understanding Parity: A Guide to Resources for Families and Caregivers.”

Caring for a child (or parent, patient or client or family member) takes a lot of dedication of time, resources, and emotions. Struggling to find access to behavioral health services can be frustrating. The full implementation of parity laws not only can provide broader access to services for immediate behavioral health needs but these laws are also important to ensuring a healthy future for people we care about. Early identification and treatment of behavioralhealth conditions, especially for children and adolescents, facilitated by parity compliance, can prevent behavioral conditions from getting worse and ultimately causing more serious problems later in life. Federal parity protections are therefore truly an investment in the future health of our children and families, and indeed all individuals living
with behavioral health conditions.

Parity Applies to How You Access Care and What You Pay

Parity applies to rules related to how mental health and substance use disorder treatment is accessed and under what conditions treatment is covered, whether permission is needed from your health plan. Benefit limitations that are not numeric are called non-quantitative treatment limitations, or NQTLs. There are special parity rules that apply to NQTLs.
Parity also means that financial requirements, such as copayments or deductibles, and numeric treatment limits such as how many visits your coverage will pay for, must be at least as generous for mental health and substance use disorder services as for physical health services. Benefits limitations that are numeric are called quantitative treatment limitations, or QTLs.

Here are some examples of how parity protections are beneficial:

• There can be no limit on the number of visits for in-network outpatient mental health and substance use disorder care, if there is no limit on the number of visits for in-network outpatient physical health care.
• The standard and basis for prior authorization requirements for mental health and substance use disorder services must be comparable to, or less restrictive than, those for physical health services. Prior authorization (sometimes called preauthorization, prior approval, or precertification) means that a health care provider from your plan must confirm that a service is needed before it begins.
• Plans must apply comparable or lower copays for out-of-network inpatient mental health and substance use disorder care than for out-of-network inpatient physical health care.
• A health plan must use a similar or less restrictive process to create and apply medical necessity standards for mental health and substance use services, compared to the process used for physical health services. If your plan denies payment for these services, your plan must give you a written explanation of the reason for the denial and must provide more information upon request.

ADDITIONAL RESOURCES

Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits Brochure
This brochure, developed by HHS, DOL, Treasury, and the Centers for Medicare & Medicaid Services (CMS), provides a consumer-oriented overview of Mental Health Parity and Addiction Equity Act (MHPAEA) (see discussion pp. 2-3). It features a list of some of the common limits placed on physical health and mental health and substance use disorder benefits and includes resources for additional information.
Link: https://store.samhsa.gov/product/Know-Your-Rights-Parity-for-Mental-Health-and-Substance-Use-Disorder-Benefits/SMA16-4971

Mental Health and Substance Use Disorder Parity Website
This DOL Employee Benefits Security Administration website includes materials on parity such as frequently asked questions (FAQs), fact sheets, publications, and videos. Expand the “For Workers and Families” section for an extensive list of resources.
Link: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-and-substance-use-disorder-parity

Parity of Mental Health and Substance Use Benefits with Other Benefits: Using Your Employer- Sponsored Health Plan to Cover Services – Guide
This DOL and HHS publication explains parity protections, gives examples of ways in which parity applies to mental health and substance use disorder benefits, and includes information about how to appeal a claim that has been denied.
Link: https://store.samhsa.gov/product/Parity-of-Mental-Health-and-Substance-Use-Benefits-with-Other-Benefits-Using-Your-Employer-Sponsored-Health-Plan-to-Cover-Services/SMA16-4937

MHPAEA Fact Sheet
This fact sheet from CMS provides an overview of Mental Health Parity and Addiction Equity Act (MHPAEA), including a summary of its protections and links to more information.
Link: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_ factsheet

MOST, BUT NOT ALL, HEALTH PLANS ARE COVERED BY PARITY LAWS

Parity only applies to health plans that provide mental health and substance use disorder benefits. In general parity applies to:

• Private-sector employment-sponsored group health plans with 51 or more workers.
• Private plans of smaller employers that started offering health insurance benefits or made major changes to their health insurance plans after March 23, 2010.
• Plans sponsored by non-federal governmental employers with 51 or more workers (although self-insured non-Federal governmental plans can opt out if they follow certain procedures).
• Most health insurance coverage sold to individuals, including coverage sold through the Health Insurance Marketplace.
• Most, but not all, Medicaid  managed care programs and all Children’s Health Insurance Program (CHIP) programs.

APPLICABLE FEDERAL LAWS

• The Mental Health Parity Act (MHPA) of 1996 provided that large, employer-sponsored (group) health plans and their insurers cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on physical health benefits
• The Balanced Budget Act of 1997 applied certain aspects of MHPA to Medicaid managed care organizations and Children’s Health Insurance Program (CHIP) benefits.
• The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) preserved the MHPA protections and added significant new protections, such as extending the parity requirements to substance use disorders. MHPAEA generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on physical health benefits.
• The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) applied the mental health and substance use disorder parity requirements of MHPAEA to coverage under CHIP state plans, in the same manner MHPAEA applies to group health plans.
• MHPAEA was amended in 2010 by the Affordable Care Act (ACA) to also apply to individual health insurance coverage and was extended to the small group market through the ACA rules related to coverage of essential health benefits.
• The ACA also expanded the application of MHPAEA to benefits in Medicaid non-managed care benchmark and benchmark-equivalent state plan benefits. Benchmark plans offer a set of essential health benefits, including mental health and substance use disorder services.
• The 21st Century Cures Act, 2016, required the Departments to issue guidance on parity. HHS was required to produce an action plan for improved federal and state coordination of parity enforcement. Employee Benefits Security Administration (EBSA) and HHS were required to report on closed federal investigations.
• The Consolidated Appropriations Act (CAA), 2021, added a requirement that group health plans and health insurance issuers must perform and document a comparative analysis of the design and application of Non-Quantitative Treatment Limitations (NQTLs). NQTLs include preauthorization for services. The comparative analysis must be made available to state and federal authorities upon request.  Participants, beneficiaries, or enrollees (or their authorized representative) may also request an NQTL analysis. The Departments are also required to request analyses if there are potential violations of or complaints about the NQTL requirements of MHPAEA and in any case at least 20 NQTL comparative analyses per year.  If sufficient information is not provided, the Departments will specify the additional information that must be submitted by the plan or issuer. After reviewing the comparative analysis and other requested materials, if the Departments determine that the plan or issuer is not in compliance with MHPAEA, the plan or issuer has 45 days to specify corrective action that it will take and to submit additional comparative analyses that demonstrate compliance. If the Departments make a final determination of noncompliance, the plan or issuer has 7 days after the determination to notify all enrolled individuals that the coverage has been determined to be noncompliant. The CAA also requires the Departments to annually report to Congress and the public findings regarding compliance of the analyses that they have requested and reviewed.