5 Things to Consider When Choosing Your Health CoverageChoosing a health insurance plan can feel like an overwhelming task. Here are five things to keep in mind when choosing health coverage for you and your family. For specific information on plan components, see your plan’s Summary of Benefits and Coverage (available from an insurance company), call the insurer directly or visit the insurer’s website. Show 1. Type of Plan and Provider Network Do the health care providers, hospitals and pharmacies you prefer fall within the plan’s network? It’s important to remember that in-netword services and medicines are covered under a plan, while out-of-network services and medicines may require additional out-of-pocket costs or may not be covered at all. Importantly, out-of-pocket costs for out-of-network services may not count toward a plan’s out-of-pocket maximum. Check to see if your preferred primary care or specialist provider and the pharmacy near your home are included in the plan’s network. 2. Premiums How much will you pay per month for coverage? Premiums are the amount you pay an insurance company for coverage, whether or not you use medical and pharmacy services. Premiums are usually paid monthly, and if you stop making payments, you are at risk of losing your coverage. Keep in mind that these are not the only costs associated with coverage. You will also be responsible for paying deductibles and for cost sharing, for example, co-pays and coinsurance, for most health care services and treatments. (See descriptions below) 3. Deductibles What is the amount you must pay out of pocket before your coverage kicks in? For example, if your deductible is $1,000, your health plan won’t pay most expenses until you’ve spent $1,000 on expenses out of pocket. Out-of-pocket costs may include specialist visits, procedure fees, and in some cases even prescriptions. Certain preventive services, such as approved cancer screenings and vaccines, are typically covered with no cost sharing before you reach your deductible. Patients who select a plan with a high deductibles will most likely have a lower monthly premium, while lower deductibles often have higher monthly premiums. Insurers increasingly require a deductible to be met before covering most medical or pharmacy services. Be sure to check with your insurer to know if your plan has either a single, combined deductible for medical and pharmacy services or a separate deductible for prescriptions to know how much you’ll have to pay before medicines are covered. 4. Co-pay or Coinsurance Are you aware of other costs that you may be required to pay to access care? Don’t forget you may be responsible for other out-of-pocket expenses even after you reach your deductible. These can include: • Coinsurance - a percentage of costs you must pay for a medicine or service, or • Co-pay - flat fees you are required to pay for prescriptions or covered services (often listed on the back of your insurance card) 5. Coverage of Medicines Are your regular prescriptions covered by your insurance plan? Each insurer has a formulary (list of medicines) covered by the plan. If a medicine is not on the formulary, it may not be covered, and patients will then have to go through a potentially lengthy process to obtain coverage. The list of covered medicines is also divided into tiers, which determine how much of a co-pay or coinsurance you may have to pay. Make a list of your current medicines, and compare it to the plan’s formulary to make sure your medicines are covered and you understand the out-of-pocket costs that may be associated with them. Contents
IntroductionThe Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.
MHPAEA does not apply directly to small group health plans, although its requirements are applied indirectly in connection with the Affordable Care Act’s essential health benefit (EHB) requirements as noted below. The Protecting Affordable Coverage for Employees Act amended the definition of small employer in section 1304(b) of the Affordable Care Act and section 2791(e) of the Public Health Service Act to mean generally an employer with 1-50 employees, with the option for states to expand the definition of small employer to 1-100 employees. The Employee Retirement and Income Security Act and the Internal Revenue Code also define a small employer as one that has 50 or fewer employees. (Some states may have mental health parity requirements that are stricter than federal requirements. To view State specific information visit www.ncsl.org, and on the right hand side of the page enter "mental health parity" then select "State Laws Mandating or Regulating Mental Health Benefits".) Summary of MHPAEA ProtectionsThe Mental Health Parity Act of 1996 (MHPA) provided that large group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical/surgical benefits.
Key changes made by MHPAEAKey changes made by MHPAEA, which is generally effective for plan years beginning after October 3, 2009, include the following:
ExceptionsThere are certain exceptions to the MHPAEA requirements. Except as noted below, MHPAEA requirements do not apply to:
Note, these exceptions do not apply to those non-grandfathered plans in the individual and small group markets that are required by Affordable Care Act regulations to provide EHB that comply with the requirements of the MHPAEA regulations. MHPAEA RegulationA final regulation implementing MHPAEA was published in the Federal Register on November 13, 2013. The regulation is effective January 13, 2014 and generally applies to plan years (in the individual market, policy years) beginning on or after July 1, 2014. See http://www.gpo.gov/fdsys/pkg/FR-2013-11-13/pdf/2013-27086.pdf for the full text of the final regulation. This followed an interim final regulation, which was published in the Federal Register on February 2, 2010 and generally applies to plan years beginning on or after July 1, 2010. See http://edocket.access.gpo.gov/2010/pdf/2010-2167.pdf - Opens in a new window for the full text of the regulation. The final regulation applies to non-Federal governmental plans with more than 50 employees, and to group health plans of private employers with more than 50 employees. It also applies to health insurance coverage in the individual health insurance market. It does not apply to group health plans of small employers (except as noted above in connection with the EHB requirements). Like the statute, it does not require group health plans to provide MH/SUD benefits. If they do, however, the financial requirements and treatment limitations that apply to MH/SUD benefits cannot be more restrictive than the predominant requirements and limitations that apply to substantially all of the medical/surgical benefits. The provisions of the regulation include the following:
We anticipate issuing further responses to questions and other guidance in the future. We hope this guidance will be helpful by providing additional clarity and assistance. If you have concerns about your plan's compliance with MHPAEA, contact our help line at 1-877-267-2323 extension 6-1565 or at . You may also contact a benefit advisor in one of the Department of Labor’s regional offices at www.askebsa.dol.gov or by calling toll free at 1-866-444-3272. Fact Sheets and FAQsRegulations and Guidance |