Was Your Child Denied Coverage for Addiction Treatment? File an Insurance Parity Complaint

When denied coverage for substance use disorder or mental health treatment, you can file an appeal with your insurance company, and you also can file a complaint with your federal or state insurance regulator and/or Attorney General. Federal and state insurance regulators are responsible for enforcing parity laws, and complaints are a critical way to identify parity violations. State Attorneys General can also investigate complaints. Therefore, it’s critical to file complaints if you suspect you are being unlawfully denied your health insurance benefits, so they will be able to ensure that everyone is receiving the care they deserve.

Under the 2008 federal law, the Mental Health Parity and Addiction Equity Act (Parity Act), you can file a complaint of non-compliance with the law. If you have been denied or received restricted care for substance use disorder treatment by the insurance company, or if you have paid more for this type of treatment than for other medical services provided in your insurance plan, it is possible that there has been a violation under the Parity Act. Filing a complaint is the first step in an investigation to determine whether your insurance company has violated the law.

Filing a complaint is an important step to alert those responsible for enforcing the Parity Act that your rights may have been violated. Responsibility for parity enforcement lies with both federal and state regulators, depending on the type of insurance you have. The Department of Labor, Employee Benefits Security Administration (DOL EBSA) is responsible for enforcing parity among large employer “self insured” plans. For state regulated health plans (individual, small group and large group fully insured plans), state insurance commissioners monitor the insurance industry. State Attorneys General can also investigate parity violations as a consumer protection matter. Government officials responsible for enforcing parity are likely to be unaware of violations unless consumers speak up.

The bottom line is that the more complaints there are from consumers, the more pressure there is for regulators and elected officials, like Attorneys General, to help enforce the Parity law.

Some states will have a set form for you to fill out online to submit a complaint. If they don’t have a form, here is a general list of what should be included in a complaint letter: your name, phone number, address, health insurance provider information (name of company, city and state, policy number), if your plan is provided by your employer or if you purchased the policy on the Marketplace, and a detailed explanation of how you have been discriminated against. We’ve included a list of common violations below that can be referenced when sending a complaint:

• If your co-pay for substance use disorder or mental health visits is higher than for other health services
• If there are stricter limits on how many visits you can receive for substance use disorder or mental health than for other health services
• If you are being charged more for a prescription drug for substance use disorder (like medication assisted treatment) or mental health than for prescriptions for other health services
• If your health provider is required to obtain prior authorization for substance use disorder or mental health treatment and is not required to do so for other health services
• If the insurer refuses to pay for treatment that your health provider deems necessary for substance use disorder or mental health, or if they make you try a less expensive treatment before covering the treatment your provider recommends
• If you are unable to find a provider in your plan’s network