Understand_Your_Mental_Health_Coverage-2.pdf

Mental Health and Substance Use Disorder Insurance Benefits

Empowering Ohioans to Understand Your Coverage A guide to navigating coverage and accessing the care you deserve. MATTERS insurance.ohio.gov/getmhia

Contact us at getmhia@insurance.ohio.gov https://insurance.ohio.gov/consumers/mental-health mailto:getmhia@insurance.ohio.gov

Table of Contents

More Things to Know Costs Associated With Your Plans Out-of-Pocket Expenses

Do You Have Insurance?

We Can Help Understanding Your Options

What Does the Law Say?

Know Your Plan Learn What Your Plan is Required to Cover

Mental Health Insurance Assistance (MHIA) Introduction ODI Mental Health Insurance Assistance Office and Partners

Navigate Your Coverage Do You Have Mental Health/Substance Use Disorder Coverage?

Is Your Mental Health Condition Covered?

Helpful Questions Create a List Ask Your Healthcare Provider

Advocate for Others Help Someone Navigate Mental Health Benefits 3 Steps to Make a Difference

Know Your Rights Request an Independent Review File a Complaint

The Ohio Mental Health Insurance Assistance Office

WE ARE AN OFFICE OF THE

The Ohio Mental Health Insurance Assistance Office (MHIA) is the state’s official resource to help consumers, mental health advocates, health care professionals, employers, and other stakeholders, understand and navigate mental health insurance benefits that are in their health plan.

We empower individuals and famlies to understand their behavioral health benefits by answering questions, providing information and attending events and trainings.

OHIO

DEPARTMENT OF

INSURANCE

Our Partners:

RECOVERYOHIO

OHIO DEPARTMENT OF MENTAL

HEALTH AND ADDICTION

SERVICES

OHIO DEPARTMENT OF

MEDICAID

U.S. DEPARTMENT OF LABOR

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage4

DO YOU HAVE INSURANCE?

Look for the mental health and substance use disorder benefits in your plan.

Mental Health Insurance

We can help.

We understand that health insurance can be confusing. We can guide you so you can focus on getting the care that you need.

Understanding your options.

Whether you have health insurance through an employer, a government program, bought it directly, or are uninsured, we’re here to help you figure it out.

We’ll help you understand your mental health coverage options and can provide resources to make finding help a bit easier.

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage 5

What Does the Law Say?

Insurers must treat mental health and substance use disorder benefits generally in the same manner as other health benefits.

Financial limitations such as copays, deductibles, and coinsurance for mental health and substance use disorder benefits cannot be more restrictive than for other health benefits. Treatment limitations such as number of visits, geographic location, or facility type cannot be more restrictive than for other health benefits.

KNOW YOUR PLAN

Some plans are required to provide mental health and substance use disorder benefits. Other plans are required to ensure that if they do offer mental health and substance use disorder benefits, they are similar to other health benefits.

How Do I Know What My Plan is Required to Cover?

Most plans you buy directly for yourself or your family (not provided through an employer) - including those sold through healthcare.gov - are required to provide mental health and substance abuse disorder benefits and ensure that those benefits are similar to other health benefits covered by the plan.

Many plans provided through an employer provide mental health and substance use disorder coverage, but not all are required to do so.

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage6

Federal and state mental health laws do not provide a specific definition of what mental health and substance use disorder benefits or services must be covered in a health plan or insurance contract. Some examples to the right show benefit categories where coverage provided for physical and mental health and substance use disorder benefits should be similar.

Check to See if You Have Mental Health/Substance Use Disorder Coverage

IS MY MENTAL HEALTH CONDITION COVERED?

Check the certificate of coverage issued by your insurer or provided by your employer.

Call your employer's human resources office.

Contact your health insurer directly.

Contact your insurance agent.

Contact the Ohio Department of Insurance at 800-686-1526.

Inpatient - If a plan covers a medically managed hospital stay for a medical condition such as a seizure disorder, then a medically managed stay for active withdrawal and stabilization of mental health condition should be similarly covered.

Outpatient - If a plan covers an office visit to the cardiologist, it should also cover an office visit to the psychiatrist.

Emergency Care - If a plan covers emergency treatment for a broken arm, it should also cover emergency treatment after a suicide threat or for an unintended overdose.

Prescription Drugs - If a plan covers maintenance medication for diabetes, it should similarly cover maintenance medication for depression and medicated assisted therapies for addiction.

Examples:

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage 7

Check the Estimated Cost of Your Out-of-Pocket Expenses in the Following Ways:

Know Your Costs

UNDERSTANDING THE COSTS ASSOCIATED WITH

YOUR PLAN:

Co-payment = the dollar amount the patient is expected to pay at the time of service.

Co-insurance = usually a $ of the total cost you are responsible for after services have been provided.

Just like your health benefits (doctors visits, prescription drugs, physical therapy), your mental health and substance use disorder benefits are subject to copays, coinsurance, deductibles, and other out-of-pocket costs.

Deductible = the amount you pay for health care expenses before insurance covers the costs. Often, health insurance plans have an annual deductible amount.

1. Check your Summary of Benefits and Coverage (SBC) in your insurance paperwork.

2. Contact your insurer directly.

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage8

HELPFUL

QUESTIONS

TO ASK YOUR HEALTH INSURANCE

PROVIDER

1. Are there specific diagnoses or services covered in my plan?

2. Are there deductibles or copayments associated with the service/treatment I am seeking?

3. What happens if I use out-of-network providers?

4. Are there limitations/exceptions to my diagnosis?

5. Do I need prior authorization or a referral for the service I am seeking?

6. What are my prescription benefits?

7. What should I do if I am denied services?

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage 9

Helping Someone Navigate Their Mental Health or Substance Use Disorder Benefits?

There are times when a person is unable to navigate their mental health and substance use disorder benefits alone. Or know what to do if they are denied treatment due to insurance. If you are advocating on behalf of someone in this position, here is what you can do:

Identify what type of plan they have and what coverage is available to them for mental health and substance use disorders by reviewing the certificate of coverage issued by their insurer or employer.

Review the in-network options available under their plan and the costs associated with using their benefits, like co-pays and deductibles, prior to seeking treatment.

If a claim denial for a benefit or service was issued by their insurer, review their appeal options with them. If they want to appeal their denied claim, you can assist them by contacting the insurer to initiate the appeal process.

You can also contact us for assistance at:

855-GET-MHIA (855-438-6442)

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage10

Know Your Rights It is important that you are familiar with your plan and the type of benefits and coverages that are offered for mental health and substance use disorder conditions. Knowing your plan can help you determine the costs you will pay and help you identify any questions you may need to ask.

YOUR RIGHTS

1. If your insurer denies your claim or takes any other adverse action regarding your benefits, you have the right to ask that your claim be reviewed again.

2. If your insurer continues to deny your claim, you have the right to request an independent review through the Ohio Department of Insurance.

If you believe that your plan has violated the law, you need more information about requesting an independent review or help filing a complaint, call the Ohio Department of Insurance CONSUMER SERVICES HOTLINE at 800-686-1526.

Additional resources to help you navigate your mental health benefits:

1. Ohio Mental Health Parity Law

2. The Mental Health Parity and Addiciton Equity Act (MHPAEA)

3. Your Guide to Health Insurance

4. Ohio Mental Health and Addiction Services

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage 11

Ohio Department of Insurance Mental Health Insurance Assistance Office (MHIA) insurance.ohio.gov/getmhia

If you are someone you know needs support now, call or text 988 or chat:

988Lifeline.org

We're here for you. Contact us at getmhia@insurance.ohio.gov

50 W Town St - Suite 300 Columbus OH, 43215

Mental Health and Substance Use Disorder Insurance Benefits: Understand Your Coverage

855-438-6442 https://insurance.ohio.gov/getmhia https://chat.988lifeline.org/ https://988lifeline.org/