In 2008, Congress passed the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). MHPAEA created standards for most large groups that required those covering mental health services to not apply stronger coverage limitations or require higher cost sharing than what the group uses for the physical health services it covers. Starting with plan/policy years after July 1, 2014, the Affordable Care Act (ACA) expanded these requirements to apply to small groups and individual health plans too. Some states have also created mental health parity requirements.
Generally, MHPAEA requires that certain group and individual health plans which provide both mental health or substance use disorder (MH/SUD) benefits and medical or surgical (M/S) benefits to:
- Apply financial requirements (like copays, deductibles, or out-of-pocket limits) or quantitative treatment limitations (like limits on covered days/services) to MH/SUD benefits in a way that is no more restrictive than the financial or quantitative requirements the plan applies to most M/S services of a similar type.
- Apply nonquantitative treatment limitations (such as prior authorization or networking rules) to MH/SUD benefits in a way that is no more restrictive than the limitations applied to M/S benefits of a similar type.
Under the regulations, the above parity requirements are applied to MH/SUD and M/S benefits across each of the following classifications and sub-classifications:
- Inpatient, in-network
- Inpatient, out-of-network
- Outpatient, in-network
- Office visit
- Other outpatient
- Outpatient, out-of-network
- Office visit
- Other outpatient
- Emergency care
- Prescription drugs
While ACA does require nearly all small group and individual plans to offer mental health or substance use disorder benefits as part of its essential health benefit requirements, MHPAEA does not actually require plans to cover mental health or substance use disorders. MHPAEA generally applies if a plan covers both mental health or substance use conditions and medical or surgical conditions.
The above information is a general overview of information related to health care plans. Your specific plan may have some differences. Content on this website is not intended to replace or amend language for any contract or coverage that you have with Blue Cross and Blue Shield of Illinois (BCBSIL).
You should always consult your plan documents and/or benefit brochure for details about what your health plan covers, as well as your rights and responsibilities under the plan. If you have questions about your specific plan, please call Customer Service at the number listed on your BCBSIL member ID card. You may also get more information on your plan’s application of mental health parity by requesting a copy of your plan’s Non-Quantitative Treatment Limitations (NQTL) documents from your employer.
You can also visit Mental Health Parity and Addiction Equity Act .