It can be absolutely heartbreaking when insurance coverage for addiction treatment for your son or daughter’s substance use is denied. You’ve worked so hard to get to this point — to get your child the help he or she needs — only to have your insurance company tell you that they won’t pay for treatment. But many parents and families don’t know that it’s within their rights to appeal. In fact, it’s illegal in most cases for insurance companies to deny coverage for substance use disorder when it’s medically necessary.
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. It is the job of the federal and state insurance regulators and state Attorney General to look into your complaint and investigate. 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.
What Does ‘Filing a Complaint’ Actually Mean?
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 as to whether your insurance company has violated the law.
Why Should I File a Complaint?
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), there are regulators called insurance commissioners who monitor the insurance industry. State Attorneys General can also investigate parity violations. While it is their job to make sure the law is being enforced and that your rights are not being violated, they are likely to be unaware of violations unless you 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 law. Enforcing the Parity law means that insurers have to provide others equal coverage for substance use disorder and mental health that they do for other medical and surgical benefits.
Where and With Whom Do I File a Complaint?
It depends on your insurance. For large employer self-funded plans, contact a Department of Labor (DOL) benefits advisor at 1-866-444-3272 or visit their website. For state-regulated plans, contact your state insurance regulator (see NAIC database). If you aren’t sure, contact either and they should be able to determine your insurance and direct you to the appropriate regulator. You can also contact your state’s Attorney General.
The Kennedy Forum’s website Parity Registry directs you how to do this easily!
You’ll be directed to how to file a complaint, based on your insurance provider and in your state of residence.
What Should Be in the Complaint?
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
What Happens After I File a Complaint?
After a complaint is filed, DOL or your state insurance commissioner’s department will send a letter and/or a copy of your complaint to the insurance company and investigate the complaint. They should also send you a copy of your complaint that was filed. Keep this record so you can follow up with DOL/the insurance commissioner’s office to see what steps have been taken.
It has been 15 years since the Parity Act has become law, and it still hasn’t been properly enforced. The truth is that lack of complaints contributes to lack of enforcement. We recognize this is an undue burden to place on individuals and families in a time of crisis while trying to obtain life-saving care. Nonetheless, complaints put critical pressure on regulators to investigate whether health plans are complying with the law. If substance use disorder and mental health benefits are being denied, insurance providers are not only discriminating against those diseases and breaking the law, they are also taking your money without providing care. We need parents to help change this, and filing a complaint is one step to making a huge difference in enforcing the Parity law and changing the landscape for those struggling with addiction.
Demand Insurance Coverage of Addiction Treatment
After you’ve filed your complaint, send a letter to Congress to demand the insurance coverage for addiction treatment that Americans are already legally entitled to under the 2008 Parity Act.