Web Content Viewer
Actions
Mental Health and Substance Use Disorder Benefits Toolkit
Mental Health and Substance Use Disorder Benefits Toolkit

Understanding your health insurance coverage for mental health and substance use disorder benefits can be complicated or difficult to navigate. The Ohio Department of Insurance has created an online toolkit to help consumers and advocates understand their benefits and coverage for mental health and substance use disorders. 

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. To learn more about how the department regulates and enforces MHPAEA, check out our Regulating MHPAEA Guide

Those with questions about appealing their insurer's health coverage decisions can call the department's consumer hotline at 800-686-1526. If you are a third party advocate or you believe your plan may be violating the law you can submit information to our ombudsman contact at ombudsman@insurance.ohio.gov.

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 800-686-1526

How to File 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:

How to Appeal a Claim Decision

Ohio law gives you the right to appeal ANY adverse determination that a health plan makes.  This includes benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility.  You are entitled to this appeal even in cases where you do not receive a denial in writing.  Appeals are easy and are requested through your health plan. 

The first step to the process is to notify your health plan you want to appeal.  This initial appeal is conducted internally by the health plan. If your health plan upholds its original determination, then you need to notify them that you want to appeal to the Ohio Department of Insurance (also referred to as external review).  Once you notify your health plan you want an external review, your health plan will proceed and send all the necessary paperwork to the department to begin the process. Once the external review is completed, you are notified that a final determination has been made.  External reviews are binding on the health plan. 

Here are a few examples:

  • You or a family member went to residential treatment for a mental health condition or substance use disorder. A request was made to the insurance company to extend the stay to continue treatment. Your insurance denied the request to extend the stay in residential treatment stating the extension is not medically necessary. At this point you are eligible for the appeals process, including external review. Further, if your provider believes your health or life may be in serious jeopardy or you may not be able to regain maximum function if treatment is delayed while you wait for a decision, you may be eligible for an expedited review for a faster decision.
  • You or a family member have been attending weekly therapist sessions for a mental health condition or substance use disorder for a month. The insurance company denied your most recent claim stating that you have met and or exceeded your visit limit and will no longer continue to cover the weekly sessions going forward. You are eligible to appeal the denial received.
  • You or a family member were recently diagnosed with a mental health condition. Your provider writes a prescription for a certain drug to treat this mental health condition; however, the insurance company denies covering that prescribed medication.  The insurance company states you will have to pay out-of-pocket for the denied medication, or they will cover a different medication than what your provider prescribed you. You are eligible to appeal the denial received.

These are only examples, all appeals are decided based on the policy language on file with the department and the medical information provided, as applicable. 

To learn more about how to appeal a decision by your health plan, visit the Understanding Health Coverage and the External Review Appeals Process page.

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.