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Mental Health and Substance Use Disorder Benefits Toolkit
Mental Health and Substance Use Disorder Benefits Toolkit

Understanding health insurance coverage for mental health and substance use disorder benefits can be complicated or difficult to navigate. This online toolkit was created to help consumers, providers, and advocates understand benefits and coverage for mental health and substance use disorders.

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Background

Laws

Generally, there are two laws that work together to create a framework for mental health and substance use disorder coverage in Ohio.

  1. State Law: A state law was enacted in 2006 requiring coverage for the diagnosis and treatment of specifically biologically based mental illness. 
  2. Federal Law: The federal parity law, the Mental Health Parity and Addiction Equity Act (MHPAEA), was enacted in 2008, generally requires health plans that provide coverage for mental health and substance use disorder benefits to provide that coverage in the same or similar manner for as physical health benefits in the same plan. 

MHPAEA and state law work together to help achieve parity among mental health and substance use disorder benefits and medical and surgical benefits:

Regulation and Enforcement

The Ohio Department of Insurance (ODI) is tasked with regulating and enforcing laws relating to the business of insurance. ODI oversees insurance policies, premium rates, company solvency, and helps consumers that have questions or complaints.

Specifically related to mental health and substance use disorder benefits, ODI reviews health insurance products to ensure that health plans are complying with MHPAEA and applicable state mental health law. ODI also helps consumers understand their mental health and substance use disorder benefits and resolve complaints against insurance companies. Finally, ODI tracks trends in consumer complaints and other data to determine if further investigation of company practices is needed.

ODI only regulates about 14% of the health insurance plans in Ohio. This chart offers a breakdown of Ohio’s health insurance market and different types of plans providing coverage to Ohioans. 

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

Consumers

As a consumer, there are times when you need assistance recognizing and navigating your mental health and substance use disorder benefits. The information below can help.

Helpful Tips for Consumers

Understanding Your Benefits

Understanding the type of plan you have will help you determine your mental health and substance use disorder benefits. Before utilizing your mental health and substance use disorder benefits it is important to understand where your insurance comes from and what coverage is available under your plan.

If you are unsure if your plan 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 (there should be a telephone number on the back of your insurance card) 
  • Contact your insurance agent
  • Contact ODI’s consumer hotline at 800-686-1526

You can also use this coverage chart to help you determine what type of coverage you may have under your health plan.

Filing a Consumer Complaint

If you have a question or concern about your mental health and substance use disorder benefits or if you are unable to resolve a complaint with your insurer you can file a consumer complaint with our Consumer Services Division (CSD). When you file a complaint, CSD will identify if your health plan handled your issue appropriately and within the terms of the policy or certificate of coverage.

When you are ready to file a complaint, it will be helpful if you have the following information handy: 

  • The name of your health plan 
  • Your policy number, group number if applicable (that is the unique identifier that attaches a policy to a specific individual and this number can be found on our insurance ID card)
  • A description of what happened and who was involved 
  • If the complaint involves a dependent under family coverage, identify the person named on the policy
  • Include any corresponding letters you have or that the company has sent you related to the dispute.

You can file a consumer complaint by: 

For additional information on filing a consumer complaint: 

Individuals with a self-insured plan can file a complaint with the U.S. 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

Appealing a Claim Denial

If you disagree with a decision made by your health plan regarding any claim denial, or reduction in benefits, often referred to as an adverse benefit determination, you have a RIGHT to appeal that decision under Ohio Law. For example, this could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility. If you have received a decision like this, you can appeal.

To begin the appeals process, notify your insurance company that you want to appeal.  The initial appeal is conducted internally by the insurer. If your insurer upholds its original determination and you would like the matter further investigated, notify your insurance company that you want to appeal to the Ohio Department of Insurance (also referred to as "external review").  Once you notify your insurer that you want an external review, they will send all the necessary paperwork to the department to begin the process. Once the external review is completed, you will be notified that a final determination has been made.  External reviews are binding on the insurance company.

If you are experiencing an emergency and your life is in serious jeopardy or you are unable to regain function if treatment is delayed, you can request an expedited review by calling your insurance company.

To learn more about how to appeal a decision by your insurance company, visit the Understanding Health Coverage and the External Review Appeals Process webpage.

Providers

As a healthcare provider, there are several ways you can assist your patients in understanding, and sometimes appealing, their mental health and substance use disorder benefits and/or claim decisions.

Helpful Tips for Providers

Appealing a Claim Decision on Behalf of a Patient

If a patient disagrees with a decision made by their health plan regarding any claim denial or reduction in benefits (often referred to as an "adverse benefit determination"), as the provider you can be deemed by the patient an "authorized representative", which affords you the RIGHT to appeal that decision under Ohio Law on their behalf. This could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility.

To begin the process, notify the patient’s insurance company of the patient's intent to appeal.  The initial appeal is conducted internally by the insurer. If the insurer upholds its original determination, then a provider acting as an authorized representative can notify the patient’s insurer that the patient intends to appeal to the Ohio Department of Insurance (also referred to as an "external review").  Once the patient’s insurer has been notified that the patient has requested an external review, the patient’s insurer will send all the necessary paperwork to the department to begin the process. When the external review is completed, the provider is notified that a final determination has been made.   External reviews are binding on the insurance company.

If the patient is experiencing an emergency and their life is in serious jeopardy or they are unable to regain function if treatment is delayed, a provider acting as an authorized representative can request an expedited review by calling the patient’s insurance company.

To learn more about becoming an authorized representative and how to appeal a decision by an insurance company, visit our Health Coverage Internal and External Review FAQs webpage.

The appeal process is included in ODI's Tips for Consumers.

Filing a Consumer Complaint on Behalf of a Patient

If a patient has a question or concern about their mental health and substance use disorder benefits or if they are unable to resolve a complaint with their insurer, you can file a consumer complaint on their behalf with ODI's Consumer Services Division (CSD). When filing a complaint, CSD will take a number of steps to identify if the patient’s health plan handled the issue appropriately and within the terms of the policy or certificate of coverage.

When you are ready to file a complaint on behalf of a patient it will be helpful if you will need to have the following information handy: 

  • The name of your health plan 
  • Your policy number, group number if applicable (that is the unique identifier that attaches a policy to a specific individual and this number can be found on our insurance ID card)
  • A description of what happened and who was involved 
  • If the complaint involves a dependent under family coverage, identify the person named on the policy
  • Include any corresponding letters you have or the company has sent you related to the dispute.

You can file a consumer complaint on behalf of a patient by: 

If you have consumers who would like to file a complaint on their own you can share ODI's Filing a Consumer Complaint information with them or direct them to www.insurance.ohio.gov for additional resources.

Individuals with a self-insured plan can file a complaint with the U.S. 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.

Filing an Anonymous Complaint Through the ODI Ombudsman

At times, a patient may not want to file a complaint with the department for one reason or another. Or as a healthcare provider, you may notice abnormalities in the way insurance companies are handling patient’s claims. The Ohio Department of Insurance has created an ombudsman email account where anonymous complaints can be filed regarding a patient or an abnormal trend. All anonymous complaints will be investigated by the department.

As an enforcement agency, it is necessary to have specific information to identify violations of the law and to determine appropriate remedies.  At a minimum, the 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 ODI Ombudsman at ombudsman@insurance.ohio.gov.

Advocates

As an advocate, there are several ways you can assist someone to understand, and sometimes appeal, their mental health and substance use disorder benefits and/or claim decisions. 

Helpful Tips for Advocates 

Helping Someone Understand Their Benefits

Understanding the type of plan someone has will help them determine their mental health and substance use disorder benefits. Before utilizing their mental health and substance use disorder benefits it is important to understand where their insurance comes from and what coverage is available under their plan.

If the person you are assisting is unsure if their plan offers mental health and substance use disorder benefits you can help them identify that information by having them:

  • Check the certificate of coverage issued by your insurer or provided by your employer
  • Contact your human resources office
  • Contact your insurer directly (there should be a telephone number on the back of your insurance card) 
  • Contact your insurance agent
  • Contact ODI’s consumer hotline at 800-686-1526

You can also use this coverage chart to help you determine what type of coverage you may have under your health plan.

Appealing a Claim Decision on Someone's Behalf

An advocate, working with someone who disagrees with a decision that was made by their health plan regarding any claim denial, or reduction in benefits (often referred to as an adverse benefit determination) can be deemed by the person they are working with as their authorized representative and can appeal the adverse benefit determination under Ohio Law. This could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility. If the person the advocate is working with has received a decision like this an advocate, acting as an authorized representative, can appeal that decision on their behalf.

To begin the process, notify the person’s insurance company of the person's intent to appeal.  The initial appeal is conducted internally by the insurer. If the insurer upholds its original determination, then an advocate acting as an authorized representative can notify the person’s insurer that the person intends to appeal to the Ohio Department of Insurance (also referred to as an "external review").  Once the person’s insurer has been notified that the person has requested an external review, the person’s insurer will send all the necessary paperwork to the department to begin the process. When the external review is completed, the advocate is notified that a final determination has been made.  External reviews are binding on the insurance company.

If the person is experiencing an emergency and their life is in serious jeopardy or they are unable to regain function if treatment is delayed an advocate acting as an authorized representative can request an expedited review by calling the person’s insurance company. 

To learn more about becoming an authorized representative and how to appeal a decision by an insurance company, visit our Health Coverage Internal and External Review FAQs webpage.

The appeal process is included in ODI’s Mental Health Parity Advocates Guide.

Filing a Consumer Complaint on Behalf of a Person

If the person you are working with has a question or concern about their mental health and substance use disorder benefits or if they are unable to resolve a complaint with their insurer, you can file a consumer complaint on their behalf with ODI's Consumer Services Division (CSD). When filing a complaint, CSD will take several steps to identify if the person’s health plan handled the issue appropriately and within the terms of the policy or certificate of coverage.

When you are ready to file a complaint on behalf of a person it will be helpful if you will need to have the following information handy: 

  • The name of their health plan 
  • Their policy number, group number if applicable (that is the unique identifier that attaches a policy to a specific individual and this number can be found on an insurance ID card)
  • A description of what happened and who was involved 
  • If the complaint involves a dependent under family coverage, identify the person named on the policy
  • Include any corresponding letters they have or the company has sent related to the dispute.

You can file a consumer complaint on behalf of a patient by:

If someone would like to file a complaint on their own you can share ODI's Filing a Consumer Complaint information with them or direct them to www.insurance.ohio.gov for additional resources.

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.

Filing an Anonymous Complaint Through the ODI Ombudsman

At times, a person may not want to file a complaint with the department for one reason or another. Or as an advocate, you may notice abnormalities in the way insurance companies are handling the person’s claims. The Ohio Department of Insurance has created an ombudsman email account where anonymous complaints can be filed regarding a patient or an abnormal trend. All anonymous complaints will be investigated by the department.

As an enforcement agency, it is necessary to have specific information to identify violations of the law and to determine appropriate remedies. At a minimum, the 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 the ODI Ombudsman at ombudsman@insurance.ohio.gov.

The appeal process is included in ODI's Tips for Providers