Mental Health and Substance Use Disorder Benefits Toolkit

July 01, 2019 | Agency

Understanding your health insurance coverage for mental health and substance use disorder benefits can be complicated or difficult to navigate. This toolkit may be helpful in better understanding your coverage.

The Law

The Federal Mental Health Parity and Addiction Equity Act (MHPAEA) was enacted into law in 2008. MHPAEA generally requires parity between benefits for mental health and substance use disorders and benefits for medical and surgical treatments under certain health plans. Ohio also has a law that requires coverage for certain biologically based mental illnesses. Both MHPAEA and the state law work together to help achieve parity among mental health and substance use disorder benefits and medical and surgical benefits.

ODI’s Role in Regulating MHPAEA

ODI is tasked with regulating and enforcing laws related to the business of insurance. ODI oversees insurance policies, premium rates, company solvency and helps consumers that have questions or complaints regarding their insurance coverage. Specifically related to MHPAEA, oversight takes many forms and involves several divisions at ODI. The three main divisions that help to oversee and enforce MHPAEA and state mental health law are:

Product Regulation and Actuarial Services: This division is the first to see a proposed insurance product and the staff here review it for compliance with MHPAEA, state mental health and other applicable laws. It is during this process that the reviewers will note and ask about provisions in the insurance contract, if any, that appear to violate the law and/or mislead or deceive the consumer. In addition, this division also conducts the actuarial review to ensure that the premium rates are actuarially justified.

Consumer Services: Consumer services is the first contact most consumers will make with ODI if they have a question about their insurance plan, are filing a complaint, or have a general insurance inquiry. If a consumer has a question about their mental health or substance abuse disorder benefits or is alleging a violation of MHPAEA, this is the division that handles the inquiry or complaint. To speak to a consumer services representative, please call the ODI hotline at 1-800-686-1526. In addition to assisting consumers, this division also tracks complaint trends to assist in monitoring companies’ compliance with MHPAEA and other insurance laws.

Market Conduct: Market conduct monitors compliance with Ohio Insurance laws and regulations by examining insurance companies’ business practices, such as underwriting, marketing and claims handling. The division gathers information from a variety of sources including consumer complaints, company filings, and the NAIC, to identify issues that should be evaluated further such as MHPAEA compliance.

Additional Information Regarding ODI’s Role in Regulating MHPAEA

Regulating MHPAEA Guide

Consumer Information

Understanding your Coverage

Understanding the type of plan you have will help you determine what mental health and substance use disorder benefits coverage are in it. Use the following coverage chart to learn what type of coverage you may have under your plan. MHPAEA Coverage Chart

If you are unsure what type of plan you have and if it offers mental health and substance use disorder benefits you can:

Check the certificate of coverage issued by your insurer or provided by your employer
Contact your human resources office
Contact your insurer directly
Contact your insurance agent
Contact ODI’s Consumer Hotline at 1-800-686-1526

Filing a Complaint

If you are unable to resolve a complaint with your insurer, you may contact the Consumer Services Division (CSD) at 800-686-1526. When you file a complaint, CSD will take a number of steps to begin working on the case to identify if there has been a violation of the law. If a complaint comes to ODI but is outside of its jurisdiction, CSD will provide you with information on how and where to file your complaint.

For questions or for help to file a claim, contact ODI’s Consumer Services Hotline at 800-686-1526

Individuals with a self-insured plan can file a complaint with the Department of Labor by calling 859-578-4680 or by visiting www.DOL.gov

Individuals who receive Medicaid benefits can file a complaint with the Ohio Department of Medicaid by calling the consumer hotline 800-324-8680 or by visiting www.medicaid.ohio.gov

Additional consumer information on how to file a complaint:

Filing an Individual Complaint

Advocate Information:

As an enforcement agency, it is necessary to have specific information in order to identify violations of law and require appropriate remedies. However, ODI understands that there may be times when an individual is unable or unwilling to file a complaint. In order to assist advocates and stakeholders, ODI has developed a process to utilize information from third parties that provide sufficient detail to allege a violation of law and allow for follow-up by ODI.

At a minimum, information provided to ODI must contain at least:

A plan or policy number
Plan type (i.e., if the consumer gets their insurance through their employer or purchases it on their own)
Name of the insurance company
A detailed description of the complaint or what happened – it is NOT enough to simply say the insurance company is violating the law

This information should be submitted to the following ODI Contact: OMBUDSMAN ombudsman@insurance.ohio.gov

Advocates should know that any information sent to the ombudsman will not be considered an individual complaint. ODI will utilize any information sent to the ombudsman to track trends related to a specific insurer or geographic area, or other trends that indicate a possible violation of insurance law.

Advocate Tip Sheet