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 firstname.lastname@example.org.
Understanding Your Coverage
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
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
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.
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