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Consumer Questions and Answers about the Mental Health Parity Act

Questions:

1. My plan has a limit of 30 visits per year on mental health benefits and pays 80 percent of the provider's usual, customary, and reasonable (UCR) charges. There is no similar visit limit on medical and surgical benefits. Is this a violation of MHPA?
2. I am in a network plan that has an annual limit for mental health benefits received out-of-network. There are no limits for out-of-network medical and surgical benefits. Does MHPA allow this?
3. If a State has a law that provides stronger protections for mental health benefits than MHPA does, which law applies?

Answers:

1) My plan has a limit of 30 visits per year on mental health benefits and pays 80 percent of the provider's usual, customary, and reasonable (UCR) charges. There is no similar visit limit on medical and surgical benefits. Is this a violation of MHPA?

No. A visit limit coupled with UCR charges is not the equivalent of an annual or lifetime dollar limit. As a result, it is NOT a violation of the MHPA requirements. Payments made by the plan on the basis of UCR charges will vary from one case to the next.

2) I am in a network plan that has an annual limit for mental health benefits received out-of-network. There are no limits for out-of-network medical and surgical benefits. Does MHPA allow this?

Yes. As long as there is parity between medical and surgical benefits and mental health benefits received in the network, then out-of-network limits do not violate MHPA

3) If a State has a law that provides stronger protections for mental health benefits than MHPA does, which law applies?

Group health plans generally are not subject to State insurance laws. State insurance laws, however, do apply to health insurance issuers, and health insurance issuers must comply with State insurance laws that provide additional consumer protections. If a group health plan provides health coverage to employees and their family members by purchasing insurance for them, health insurance issuers may be required to comply with State insurance laws that provide stronger protections than MHPA. Click on the name of your State insurance department under "Contacts" to find out who you should contact for additional information.