Mental Health Parity - Frequently Asked
Questions
The main provisions of the Ohio Mental Health Parity law can
be found in sections 1751.01, 3923.28, 3923.281 and 3923.282
of the Ohio
Revised Code.
Q: What benefits must be provided under the Mental Health
Parity law?
A: Benefits must be provided for the diagnosis and treatment
of biologically based mental illness (“BBMI”) on
the same terms and conditions as, and no less extensive than,
those provided for the treatment and diagnosis of all other
physical diseases and disorders. A Health Insuring Corporation
(“HIC”) that offers coverage for any other basic
health care service must offer coverage for diagnostic and
treatment services for biologically based mental illnesses.
Q: When must these benefits be provided?
A: Insurance policies and plans of health coverage
that are established, delivered, issued for delivery, modified
or renewed in Ohio on or after October 1, 2007, must include
these benefits.
Q: Which types of insurance policies must include
coverage for BBMI?
A: The Ohio Mental Health Parity law, as amended by
the 2007 biennium Budget Bill, requires that every policy of
sickness and accident insurance, including group, individual,
and blanket insurance, but excluding the types of policies
listed in the answer to Question 6 below, must provide the
required BBMI benefits. The law also applies to both individual
and group evidences of coverage offered by HICs that provide
coverage for “basic health care services.”
Q: Does coverage extend to benefits offered by self-insured
employers?
A: Yes. The Ohio Mental Health Parity law applies
to plans of health coverage offered by private or public self-insured
employers, unless federal law supersedes, preempts, prohibits,
or otherwise precludes its application. For example, public
employee pension plans would be subject to the parity requirements,
but private, single employer self-insured plans would not be
subject to the requirements.
Q: Will insurance policies provided through non-employer
association groups, unions or trusts be required to include
BBMI coverage?
A: Yes. The law applies to non-employer based insurance
plans, such as those provided through associations, unions
or trusts.
Q: What types of insurance products are not covered
under this new law?
A: The Mental Health Parity law does not apply to
Medicaid, Medicare, hospital indemnity, medicare supplement,
long-term care, disability income, one-time-limited duration
policies of not longer than six months (short-term), supplemental
benefit or other policies that provide coverage for specific
diseases or accidents only, worker’s compensation or
any federal health care program.
Q: Does Ohio’s Mental Health Parity law apply
to benefits for substance abuse or chemical dependency treatment?
A: No. Substance abuse and chemical dependency are
not included in the definition of BBMI.
Q: Can mental health benefits continue to be “carved
out” from other medical benefits and contracted for
separately by employers or insurers?
A: Yes. Benefits for mental health treatment can continue
to be provided through separate contracts; however, those contractual
arrangements may need to be adjusted to comply with the Mental
Health Parity law’s requirement that the insurance policy
include benefits for BBMI. Benefits provided for BBMI outside
of an insurance policy must comply with the law’s requirement
that they be subject to the same terms and conditions as benefits
provided for all other physical diseases and disorders.
Q: Does Ohio’s Mental Health Parity law prohibit
deductibles, co-payments and/or other cost-sharing elements
being applied to BBMI services?
A: No. Deductibles and co-payments are not prohibited
as long as such cost-sharing limitations are equally applied
to services for the treatment of physical illness and disorders.
For example, the inpatient deductible for a hospital stay to
treat BBMI must be the same as the inpatient deductible to
treat physical illnesses. If a plan requires a higher co-payment
to use a specialist, then a person seeking treatment from a
specialist for BBMI may be required to pay the higher specialist
co-payment.
Q: Can a policy or plan of health coverage require
that services for BBMI be pre-authorized?
A: Yes. A plan may require pre-authorization for particular
services for the treatment of BBMI only if pre-authorization
is required for the same services when provided to treat physical
illness. For example, a carrier that requires pre-authorization
for all hospital admissions may require pre-authorization for
a hospital admission for BBMI. Similarly, pre-authorization
may be required specifically for outpatient treatment of BBMI
only if it is required for outpatient treatment for all other
physical diseases and disorders, or for all other outpatient
basic health care services for HICs.
Q: Is there a requirement to provide coverage for
prescription drugs associated with the treatment of BBMI?
A: No. Prescription drug coverage for the treatment
of BBMI is not a mandated benefit. However, if the health plan
provides prescription drug coverage, then the coverage shall
include prescription drugs to treat BBMI.
Q: If every group sickness and accident insurance
policy is now required to provide coverage for BBMI, does
this mean that the $550 outpatient benefit mandate for mental
or emotional disorders is also triggered?
A: Yes. Pursuant to Section
3923.28 of the Revised Code, every group policy that provides
coverage for mental or emotional disorders shall provide at
least $550 of outpatient benefits for mental or emotional disorders
for each eligible person. It is the Department’s interpretation
that coverage for BBMI is coverage for a mental disorder, therefore
in addition to coverage for BBMI, every group policy of sickness
and accident insurance must also comply with the requirement
to provide at least $550 of outpatient benefits for mental
or emotional disorders. The Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition comments upon the fact
that there is not an agreed upon definition of mental disorders
and points out that there is much “physical” in “mental” disorders
and much “mental” in “physical” disorders.
However, it is the Department’s view that the more persuasive
argument is that coverage for BBMI can not be considered as
coverage solely for a physical disorder and therefore should
be considered as coverage for a mental disorder.
Please note that Section
3923.28(F) of the Revised Code provides that the $550
of outpatient benefits for mental or emotional disorders
required under this section may not be reduced by the cost
of benefits provided for BBMI.
Please also see Section
3923.30 of the Revised Code with regard to public and
private plans of health care benefits.
Q: Will the Mental Health Parity law affect the definition
of “eligible provider(s)” within the terms of
health insurance coverage?
A: Yes. Prior to the enactment of this law, only licensed
physicians and psychologists were required to be reimbursed
for providing covered mental health services. Under the new
law, the definition of eligible providers includes clinical
nurse specialists whose nursing specialty is mental health,
professional clinical counselors, professional counselors and
independent social workers. Such practitioners must be included
as eligible providers within the terms of health insurance
policies, certificates and plans of health coverage.
Q: Are form filings required by health insurance companies
and HICs in order to comply with the Mental Health Parity
law?
A: Yes. To the extent required to bring existing policies
or contracts into compliance with these new requirements, insurance
companies and HICs must submit revised policies, contracts,
certificates, evidences of coverage forms and other related
filings or submit riders/endorsements.
Q: Are there any special requirements for filings?
A: Yes. When filing riders/endorsements/amendments
to existing forms, we request that companies identify all affected
policies, certificates, amendments, riders and/or forms that
may have previously been approved and supply the Ohio Department
of Insurance File Number and approval date(s) for each.
Q: How does the Mental Health Parity law affect Ohio
Health Care Basic and Standard plans?
A: The Board of the Ohio Health Reinsurance Program
has revised the benefit designs for the basic and standard
HIC and indemnity plans to include coverage for BBMI.
Q: Must the employer absorb the additional cost of
this coverage, if any?
A: The bill does not require an employer to assume
any additional cost to achieve parity. Therefore, some (or
all) of the increased costs could be passed on to the employee.
Q: If there are changes to the federal mental health
parity law, will Ohio’s mental health benefits change?
A: Maybe. It depends upon the extent of the changes
made in federal law and to what degree the changes impact Ohio’s
laws.
Q: How does the "opt out" provision for
insurers work?
A: In order for an insurance company to "opt
out" of providing benefits for BBMI, the company must
request and qualify for an exemption as determined by the Department
of Insurance.
Q: If a health insurance carrier or HIC intends to
request an exemption from providing BBMI benefits, can they
provide evidence based upon actuarial studies of previously
incurred historical claims expenses and/or industry-wide
claims data?
A: No. The law provides that in order to request an
exemption, the documentation must be based upon actual “incurred
claims for diagnostic and treatment services for BBMI for a
period of at least six months” after the mandate has
been in effect.
Q: Is there any difference between a health insurance
carrier and a HIC in the type of claims data that must be
presented in order to request an exemption?
A: Yes. For Title 39 insurance companies, the documentation
must show that the claims incurred as a result of providing
the required BBMI coverage “independently caused the
insurer’s costs for claims and administrative expenses
for coverage of all other physical diseases and disorders to
increase by more than one per cent per year” (emphasis
added). HICs must provide the same actuarial certification;
however, the documentation must demonstrate that the BBMI claims
expenses caused the HIC’s costs for claims and administrative
expenses for the coverage of basic health care services (which
includes BBMI) to increase by more than 1% per year.
Q: Who should be contacted for further information
regarding coverage under this new law?
A: For questions regarding specific insurance coverage,
insureds/enrollees should contact their respective insurance
companies or HICs. Employees covered under self-funded plans
should contact their employers or plan administrators. For
questions regarding general health insurance and for specific
questions regarding coverage under the BBMI law, Ohio residents
may contact the Consumer Services Division of the Ohio Department
of Insurance at 1-800-686-1526. Companies with questions regarding
coverage under the law may contact the Life and Health Division
of the Ohio Department of Insurance at (614) 644-2644.
