Access to mental health and substance use disorder services is determined in part by the insurance coverage of these services and by the terms under which the services are covered. Federal parity law and the health reform law affect both the coverage of mental health and substance use disorder services, as well as the terms under which they are covered. Federal law requires parity in annual and aggregate lifetime limits, treatment limitations, financial requirements, and in- and out-of-network covered benefits. However, federal parity law does not mandate the coverage of mental health and substance use disorder services. The health reform law builds on federal parity law and also contains provisions that mandate coverage of mental health and substance use disorder services. The health reform law (the Patient Protection and Affordable Care Act of 2010 [ P.L. These include (1) Qualified Health Plans (QHPs), the plans that will be offered through the Exchanges; (2) plans offered through the individual market; and (3) Medicaid benchmark and benchmark-equivalent plans (that are not managed care plans). This approach, where the coverage of mental health and substance use disorder services is not required, but where parity with medical and surgical services is required if mental health and substance use disorder services are covered, is termed a mandated offering parity approach. The ACA does not require that specific mental health and substance use disorder services be included as part of the EHB. Are All Plans Required to Cover the EHB or the EHBP? It specifically requires four types of plans to offer either the EHB or EHBP: (1) new plans offered through the individual market; (2) new plans offered through the small group market; (3) QHPs; and (4) Medicaid benchmark and benchmark equivalent plans. Mental Health Parity and Mandated Coverage of Mental Health and Substance Use Disorder Services Provisions in the ACA
Two important components of access to mental health and substance use disorder services are their insurance coverage and the terms under which they are covered. Federal mental health parity law addresses the terms under which mental health and substance use disorder services are covered in comparison with medical and surgical services in those plans that choose to offer coverage of these services. Federal law requires parity in annual and aggregate lifetime limits, treatment limitations, financial requirements, and in- and out-of-network covered benefits. However, federal parity law does not mandate the coverage of mental health and substance use disorder services.
The Patient Protection and Affordable Care Act of 2010 (ACA, P.L. 111-148), as amended, contains provisions that address both the coverage of mental health and substance use disorder services and the terms under which these services are covered. Specifically, the ACA includes provisions that require (1) compliance with federal parity law by certain plans and (2) the coverage of mental health and substance use disorder services by certain plans.
The ACA does not change the federal mental health requirements at all. However, it extends applicability of these requirements to three new plan types: (1) Qualified Health Plans (QHPs, offered through the state Exchanges); (2) plans offered through the individual market; and (3) Medicaid benchmark and benchmark equivalent plans that are not managed care plans.
The ACA also requires certain plans to offer coverage of mental health and substance use disorder services, by requiring these plan types to cover the Essential Health Benefits (EHB), which are defined to include mental health and substance use disorder services. The ACA requires coverage of the EHB, and therefore at least some mental health and substance use disorder services, by the following plan types: (1) QHPs; (2) new plans offered through the individual or small group market; and (3) Medicaid benchmark and benchmark-equivalent plans.