What the Mental Health Parity and Addiction Equity Act requires, where it falls short, and how to use it in an appeal. It has been the law for nearly two decades. And it is routinely violated.
The Mental Health Parity and Addiction Equity Act (MHPAEA), passed in 2008 and strengthened by the ACA, requires that health plans covering mental health or substance use disorder benefits must apply the same treatment limitations as they apply to medical and surgical benefits. Parity applies to financial requirements (deductibles, copays, coinsurance), quantitative treatment limits (number of inpatient days, outpatient visits covered), and non-quantitative treatment limits (prior authorization requirements, step therapy, medical necessity criteria, network adequacy).
The law does not require a plan to cover mental health care. But if the plan covers it, the coverage must be on equal terms with medical and surgical coverage.
If your mental health or substance use disorder treatment was denied, ask: What is the specific criterion or treatment limit applied to my denial? Does the plan apply the same criterion to comparable medical or surgical care — and if not, why not?
Request the plan's Comparative Analysis of Non-Quantitative Treatment Limitations. This document shows how the plan determined that its mental health restrictions are equivalent to its medical restrictions. If the analysis is incomplete or reveals an unequal standard, include that comparison explicitly in your appeal. State that the plan's denial appears to violate the Mental Health Parity and Addiction Equity Act and cite the specific unequal limitation.
The California Department of Managed Health Care has been among the most active state enforcers, regularly taking action against insurers including Carelon Behavioral Health and Anthem for parity violations.
