If you get health insurance through your job in New York or New Jersey, your plan must treat mental health equally to physical health. Yet many workers still face higher costs or strict approval requirements for therapy or psychiatric treatment. In several cases, this violates the law.
Federal laws like ERISA, the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA) require fair and equal coverage. Here’s what that means for you.
What laws apply?
Most private employer-sponsored health plans are governed by ERISA, a federal law that requires fairness, transparency and a clear appeal process when claims are denied. However, government and church-affiliated plans are generally exempt.
The MHPAEA and the ACA require health plans that offer mental-health or substance-use-disorder benefits to treat those services the same as physical medical care. For example, your plan must follow parity in three key areas:
- Copay fairness: It cannot charge higher copays for therapy than for a primary care visit.
- Session limits: It cannot limit the number of therapy sessions if it allows unlimited physical therapy.
- Prior-authorization parity: It cannot require extra approvals for mental health services unless it does so for similar physical conditions.
The ACA extended these parity rules to a number of individual and small group plans. But what exactly do these laws require health plans to cover?
What conditions must your health plan cover?
Health plans typically fall under essential health benefits required by law. They often include coverage for the following conditions:
- Mood disorders: Conditions like depression, anxiety and PTSD
- Psychotic disorders: Conditions like bipolar disorder and schizophrenia
- Neurodevelopmental disorders: Conditions like ADHD and autism
- Behavioral and addiction disorders: Conditions like eating disorders and substance use disorders
Your insurer cannot apply more restrictions to these conditions than it does to comparable physical illnesses. If your coverage falls short or you face denials, there are steps you can take to challenge it.
How to protect your rights
Review your plan’s Summary Plan Description (SPD) to see how it covers mental health services. Compare them to how it handles physical health services. If your plan applies different rules, request a written explanation for why it denied your claim.
You can also file a complaint with:
- The U.S. Department of Labor – if your plan is covered by ERISA
- Your state’s insurance department – if ERISA does not apply to your plan
Taking these steps can help you identify illegal coverage practices and take action to ensure you receive the benefits the law guarantees.
Don’t settle for unequal coverage
Mental health deserves the same level of coverage as physical care; if your plan treats it differently, you may have the legal right to challenge that decision. Understanding these protections is the first step toward getting the care you need and deserve.