CONSUMER TIPS

							                  CONSUMER TIPS
                From the Vermont Division of Health Care Administration

     Health Insurance Coverage for Mental Health and
         Substance Abuse Treatment in Vermont
Vermont’s “Health Insurance Coverage for Mental Health and Substance Abuse
Treatment” law became effective on January 1, 1997. It was enhanced in 2007. The
law requires insurers to provide coverage for mental health and substance abuse
services at the same level as other health services covered under the health insurance
plan.

                     Frequently Asked Questions
Why providing equality of health insurance coverage to both mental health and
substance abuse services as those for other health conditions is important to me?

Before Vermont’s “Health Insurance Coverage for Mental Health and Substance
Abuse Treatment” law, some health insurers provided less health insurance
coverage of mental health and substance abuse conditions compared to other health
conditions. As a result, people with mental health or substance abuse conditions
often found themselves in need of treatment but without the means to pay for it.

The law assures equitable mental health and substance abuse care benefits to be
included in all new health insurance policies. In addition, it eliminates separate and
unequal deductibles and out-of-pocket costs for mental health and substance abuse
services. It also removes separate yearly and lifetime dollar limits and dollar
maximums.

Are health insurers allowed to sell different types of mental health and substance
abuse benefit packages?

Yes. Health insurers are allowed to offer benefit options with different out-of-pocket
costs as long as one of the options provide the same coverage for mental health and
substance abuse as other covered health services. For example, an insurer may
allow you to choose a provider who is not in their network, but you may have to pay
more for this service. This must apply whether it is for mental health or substance
abuse services or another covered health service.
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Does Vermont mental health and substance abuse health insurance law apply to
Medicaid benefits?

Yes, the law applies to coverage for Vermont Medicaid beneficiaries.

I asked for mental health or substance abuse benefits and my insurer denied
them. What can I do?

If you are covered by private health insurance and you have been denied mental
health or substance abuse care benefits that you feel are necessary, you must first
attempt to settle the dispute with your insurer. Contact your insurer by mail or
phone as soon as possible after receiving the denial letter. Keep all letters received
from your insurer regarding the denial.

If you are unable to resolve the problem through the “internal” appeal process, you
may then pursue an “external” appeal for mental health and substance abuse claims.
External appeals are processed through the Vermont Independent Panel of Mental
Health Providers, a committee of mental health and substance abuse professionals
appointed by the Commissioner of the Department of Banking, Insurance, Securities
and Health Care Administration. The Panel will reconsider, and in appropriate
cases, reverse unfavorable decisions. It cannot, however, change the insurance
contract between you and your insurer (for example, by requiring the insurer to pay
for services not covered under the contract).

                         How to Appeal a Denial
To print the form to appeal a denial of mental health benefits to the Independent
Panel of Mental Health Care Providers:
http://www.bishca.state.vt.us/HcaDiv/consumer_help/AppealApp_IP08_denial_
mentalhealth.pdf

For members covered by “Medicaid health insurance” appeals are processed
through the Human Services Board. Contact them at (802) 828-2536, or send a letter
to the Human Services Board, 120 State Street, Montpelier, 05620-4301.

To print the form to request a fair hearing for a denial of mental health Medicaid
benefits: http://humanservices.vermont.gov/boards-committees/hsb/request-for-
a-fair-hearing


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     Key Federal Mental Health Parity and Addictions
                 Equality Requirements
The 1996 federal Parity Act banned health insurers from putting lifetime or annual
dollar limits on mental health services. The federal Mental Health Parity and
Addictions Equality Act of 2008 (“the Act”) builds upon the federal 1996 Parity Act,
which goes into effect for most plans by January 1, 2010. The Act applies to all group
health plans with 51 or more employees, including self-insured employer plans. The
Act does not preempt state laws. In addition, it amended the 1996 Parity Act to
include substance use disorders.

The Act does not mandate that any mental health and substance abuse conditions be
covered under health plans. Nor does the Act require a plan to offer mental health
or substance abuse coverage. What the Act does require is that for any mental health
or substance abuse condition covered under a plan, the coverage must be at parity
with the plan’s medical and surgical coverage benefits. Specifically, group health
plans cannot offer coverage for mental helath or substance abuse conditions that
imposes stricter treatment limitations or financial requirements than for medical and
surgical coverage.

A key requirement of the Act is that cost sharing and deductibles must be the same
between a plans’s coverage for mental health or substance abuse conditions and
medical and surgical conditions. In addition, the Act requires that if a plan offers
out-of-network coverage for medical or surgical care, then it must also offer out-of-
network coverage for mental health and substance abuse care. There must be parity
in the out-of-network benefits for mental health and substance abuse and medical
and surgical care.

Individuals interested in obtaining additional information on the Mental Health
Parity Addictions Equality Act of 2008 Act and other health care laws may request
copies of Department of Labor publications concerning changes in health care law
by calling the EBSA Toll-Free Hotline at 1-866-444-EBSA (3272), or access the
publications on-line at http://www.dol.gov/ebsa, the Department of Labor's Web
site.

               State of Vermont
               Department of Banking, Insurance,
               Securities & Health Care Administration
               89 Main St. Montpelier, VT 05620-3101
               Consumer Assistance: 1-800-631-7788.
                               (Posted Date: November 2009)
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