Mental Health and Substance Use Disorder Parity and Reporting Information
Access to treatment for mental health and substance use disorders (MH/SUD) is essential to the health and well-being of all New Yorkers. MH/SUD services must be covered in health insurance policies sold in New York. If you are a consumer looking for information about your insurance coverage for MH/SUD treatment, please visit our MH/SUD consumer information page.
Federal Laws Governing Parity
The federal Mental Health Parity Act of 1996 required that large group health plans could not impose lifetime dollar limits on mental health benefits that were less favorable than the limits imposed on medical and surgical benefits. Since then, additional federal parity laws related to mental health have been passed.
The federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) ensures that group health insurance plans treat MH/SUD and M/S benefits similarly by preventing health insurance plans from imposing less favorable benefit limitations on MH/SUD than on M/S benefits. An Amendment to the Affordable Care Act (ACA) added this coverage requirement to individual health plans as well.
The following links provide additional information on federal MHPAEA and parity requirements:
- Centers for Medicare and Medicaid Services. The Mental Health Parity and Addiction Equity Act (MHPAEA)
- U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration: Behavioral Health Equity
- The Federal Register. Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
- Legal Information Institute. 45 CFR § 146.136 - Parity in mental health and substance use disorder benefits
State Laws Governing Parity?
New York Insurance Law requires insurance coverage to be consistent with MHPAEA and imposes additional MH/SUD coverage requirements. The following New York laws, regulations, and industry guidance provide information on MH/SUD requirements.
Laws
|
MH/SUD |
GROUP COMMERCIAL HEALTH INSURANCE POLICIES |
INDIVIDUAL COMMERCIAL HEALTH INSURANCE POLICIES |
HMO/ARTICLE 43 HEALTH INSURANCE POLICIES |
|---|---|---|---|
|
Inpatient SUD Services |
§3221(l)(6) |
§3216(i)(30) |
§4303(k) |
|
Outpatient SUD Services |
§3221(l)(7) |
§3216(i)(31) |
§4303(l) |
|
Inpatient and Outpatient MH Services |
§3221(l)(5) |
§3216(i)(35) |
§4303(g) |
|
Prescription Medications to Treat SUD |
§3221(l)(7-b) |
§3216(i)(31-a) |
§4303(l-2) |
|
SUD Clinical Review Criteria |
§4902(a)(9) |
§4902(a)(9) |
§4902(a)(9) |
|
MH Clinical Review Criteria |
§4902(a)(12) |
§4902(a)(12) |
§4902(a)(12) |
|
Participating Provider Directory |
§§3217-a(a)(17) |
§§3217-a(a)(17) |
§4324(a)(17) |
|
Disclosure of Comparative Analysis |
§3217-a(a)(21) |
§3217-a(a)(21) |
§4324(a)(22) |
Regulations
- Mental Health and Substance Use Disorder Parity Compliance Program (Regulation 218)
- Cost-Sharing Waiver for Telehealth Services (58th Amendment to Regulation 62)
Circular Letters
- Supplement No. 2 to Circular Letter No. 8 (2020). Coronavirus and Resumption of Preauthorization and Concurrent and Retrospective Review, Utilization Review Requirements, and Payments to Participating Hospitals
- Insurance Circular Letter No. 10 (2020). Coronavirus and Mental Health Services for Essential Workers
- Insurance Circular Letter. No. 14 (2019). Health Insurance Coverage for Peer Support Services Provided as Part of a Substance Use Disorder Outpatient Program
- Insurance Circular Letter No. 13 (2019). Health Insurance Coverage for Mental Health Conditions and Substance Use Disorder
- Insurance Circular Letter No. 13 (2018). Preauthorization of Substance Use Disorder Treatment
- Insurance Circular Letter No. 12 (2018). Formulary Tier Placement of Opioid and Non-Opioid Drugs Prescribed for Pain Management
- Insurance Circular Letter No. 16 (2017). Health Insurance Coverage for Naloxone
- Insurance Circular Letter No. 14 (2017). Substance Use Disorder Treatment, Prevention, and Utilization Review
- Insurance Circular Letter No. 6 (2016). Coverage for Substance Use Disorder Treatment
- Insurance Circular Letter No. 4 (2016). United States Department of Labor and United States Department of Health and Human Services Compliance Guidance “Warning Signs – Plan or Policy Non-Quantitative Treatment Limitations (NQTLs) that Require Additional Analysis to Determine Mental Health Parity Compliance”
- Insurance Circular Letter No. 6. (2015). Changes in Utilization Review Standards for Substance Use Disorder Treatment Pursuant to Chapter 41 of the Laws of 2014
- Insurance Circular Letter No. 5 (2014). Impact of mental Health Parity and Addiction Equity Act of 2008 (“MHPAEA”), Affordable Care Act (“ACA”), and the MHPAEA Final Rule on Mental Health and Substance Use Disorder Benefits in New York’s Health Insurance Market
Industry FAQs
- Mental Health and Substance Use Disorder (MH/SUD) FAQs