CONSUMER GUIDE TO DISCLOSURE RIGHTS: MAKING THE MOST OF

YOUR MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS 
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

2

ACKNOWLEDGMENTS

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services

(HHS), in consultation with the Employee Benefits Security Administration (EBSA), U.S. Department of Labor (DOL), by Truven Health Analytics, an IBM 

Company, under SAMHSA IDIQ Prime Contract #HHSS283200700029I, Task Order #HHSS28342002T with SAMHSA, HHS. Mariel Lifshitz served as the 

Government Project Officer.

DISCLAIMER

This document is not meant to be considered legal advice and is not representative of the official position of the U.S. Departments of Labor, Health and Human

Services, and the Treasury. This document is intended to give a basic understanding of certain requirements related to MHPAEA and claims and appeals under

the Public Health Service Act (PHSA), the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code (the Code). The statute, recent

regulations, and other guidance issued by the Departments should be consulted. 

SAMHSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SAMHSA

cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

PUBLIC DOMAIN NOTICE

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA and DOL. Citation of the

source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of SAMHSA, HHS

and EBSA, DOL. 

ELECTRONIC ACCESS AND COPIES OF PUBLICATION

This publication may be downloaded on the Substance Abuse and Mental Health Services Administration website at http://store.samhsa.gov or the U.S.

Department of Labor, Employee Benefits Security Administration website at www.dol.gov/agencies/ebsa.

RECOMMENDED CITATION

Substance Abuse and Mental Health Services Administration. Consumer Guide to Disclosure Rights: Making the Most of your Mental Health and Substance Use

Disorder Benefits. HHS Publication No. (SMA)16-4992, Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.

ORIGINATING OFFICES

Office of Policy, Planning, and Innovation, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, 18E85C, Rockville, MD 20852. U.S.

Department of Labor, Employee Benefits Security Administration, 200 Constitution Avenue, NW, Washington, DC 20210. 

HHS Publication: No. (SMA)16-4992
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

3

CONSUMER GUIDE TO DISCLOSURE RIGHTS: MAKING THE MOST OF YOUR MENTAL HEALTH AND

SUBSTANCE USE DISORDER BENEFITS

One of the many important components of both the Affordable Care Act and the Mental Health Parity and Addiction Equity Act is to

ensure that health plans treat mental health and substance use disorders the same way that they treat other health issues. The Mental

Health Parity and Addiction Equity Act requires group health plans and insurers that offer mental health and substance use disorder

benefits to provide coverage that is comparable to their coverage for general medical and surgical (medical/surgical) care. Limitations on

mental health and substance use disorder benefits (such as copayments, visit limits, and preauthorization requirements) must generally

be comparable with those for medical/surgical benefits.

i

The parity law, also known as the Mental Health Parity and Addiction Equity Act, and other laws require transparency and disclosure of

information. This publication provides a general explanation of the various federal disclosure lawsii affecting private-sector, employersponsored group health plans and health insurers. The following table provides information about important documents that may be

available to you under various federal laws. This resource can help you better understand what information to request to help determine

which mental health or substance use disorder benefits will be paid for by your health plan, what information your plan relies on to

approve or deny benefits, and what information is available to help you determine if your plan’s mental health and substance use disorder

benefits are offered at parity. In general, employees and former employees who are eligible to enroll in the plan or who may become

eligible to enroll in the plan (referred to as “participants”), their covered family members (referred to as “beneficiaries”), and an

authorized representative (such as an appropriately authorized family member or medical provider acting on behalf of a participant or

beneficiary) are entitled to receive this information.

Under the Mental Health Parity and Addiction Equity Act and other Federal laws, you are entitled to many different documents related to

your mental health and substance use disorder and medical/surgical benefits. These scenarios offer suggestions of certain documents you

may want to request, but you have a legal right under the Mental Health Parity and Addiction Equity Act and other federal laws to request

additional information, if you believe it will be helpful. While this document will assist you in understanding your rights to information that

may be helpful, it is not a comprehensive description of these laws and should not be considered legal advice. For other types of

coverage, such as individual market coverage, you should check with your state department of insurance for the most accurate

information regarding your disclosure rights. Also, your state may have other laws that affect your behavioral health coverage. The

National Association of Insurance Commissioners at http://naic.org/state_web_map.htm provides access to state websites with

information on particular state health insurance laws.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

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A glossary defining common health plan and legal terms is included at the end of this publication. These terms and definitions are

intended to help you understand this document and may be different from the terms and definitions used by your plan. Some of these

terms also might not have exactly the same meaning when used in your policy or plan, and in that case, the policy or plan governs.

Common scenarios that may affect your mental health and substance use disorder benefits

**Important note: You may fit into more than one scenario at a time. Review all the scenarios to see all the information that is relevant

for you.

SCENARIO WHERE TO START?

SUGGESTIONS FOR INFORMATION YOU HAVE A RIGHT TO THAT CAN HELP WHEN CAN I GET THESE DOCUMENTS?

1. I am thinking about

changing health

coverage and would

like to understand the

benefits available

under my coverage

options (known as a

benefits overview).

A Summary of Benefits and Coverage

The Summary of Benefits and Coverage provides a brief description of

benefits and coverage under a plan, including coverage of mental health and

substance use disorder benefits. The Summary of Benefits and Coverage

includes:

1. A description of the health coverage (including cost sharing, such as

deductibles, co-insurance, and copays);

2. The exceptions or changes to the benefit plan, and limitations on

coverage; and

3. Coverage examples.

If you have more questions after reviewing your Summary of Benefits and

Coverage, request a Summary Plan Description, described below.

Summaries of Benefits and

Coverage are distributed with initial

enrollment materials and annually.

They also must be provided upon

request, generally within seven

business days. 

If a plan makes a significant mid-year

coverage change that would affect the

contents of the Summary of Benefits

and Coverage, it must send out a

notice at least 60 days before the

change takes effect.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

5

SCENARIO WHERE TO START?

SUGGESTIONS FOR INFORMATION YOU HAVE A RIGHT TO THAT CAN HELP WHEN CAN I GET THESE DOCUMENTS?

2. I am not sure what

mental health and

substance use disorder

treatments my plan will

pay for, or if there are

limits or exclusions on

these benefits. 

Summary Plan Description and any Summaries of Material Modifications.

Summary Plan Descriptions are important disclosure documents prepared by

the plan that describe, in understandable terms, the rights, benefits, and

responsibilities of participants and beneficiaries. The Summary Plan

Description must include important information regarding the plan, such as

information on how the plan works, eligibility requirements, what benefits

the plan provides, and how those benefits may be obtained, including how

the plan covers mental health and substance use disorder benefits. The

plan’s claims procedure, including applicable time frames, must also be

included in the Summary Plan Description, or in a separate document

distributed with the Summary Plan Description. 

Summaries of Material Modifications describe important changes made to

the plan and the Summary Plan Description.

Summary Plan Descriptions are

generally distributed within 90 days

after the date a participant first

becomes covered by the plan. They

also must be provided upon written

request, generally within 30 days.

Summaries of Material Modifications

that describe an important reduction

in covered services or benefits must

generally be provided automatically

within 60 days of the change taking

effect.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

6

SCENARIO WHERE TO START?

SUGGESTIONS FOR INFORMATION YOU HAVE A RIGHT TO THAT CAN HELP WHEN CAN I GET THESE DOCUMENTS?

3. My plan says it will

cover medically

necessary treatment.

How do I know what

the plan considers to

be medically

necessary?

Medical necessity criteria for the treatment.

These documents provide rules for determining medical necessity for specific

mental health and substance use disorder treatment, including criteria that

determine whether a person qualifies for a specific mental health and

substance use disorder benefit and how the plan developed these medical

necessity criteria. A person can request medical necessity criteria for

medical/surgical benefits, and information to verify the plan applies the

criteria in a comparable way to the medical necessity criteria for mental

health and substance use disorder benefits.

For example, you could request the medical necessity criteria for inpatient

treatment of eating disorders. In addition to the medical necessity criteria,

the plan must identify what information or processes were used to develop

the medical necessity criteria for both medical/surgical and mental health and

substance use disorder benefits. For instance, if a plan claims that its medical

necessity criteria is based primarily on a specific established treatment

guideline, such as the American Psychiatric Association’s latest Practice

Guideline for the Treatment of Patients with Eating Disorders and Guideline

Watch, the plan must disclose these guidelines.

Similarly, if a plan claims that its medical necessity criteria for treatment of

opioid use disorder is based primarily on a specific established treatment

guideline, such as the criteria put forth by the American Society of Addiction

Medicine for Treatment of Substance Use Disorders, the plan must disclose

these guidelines.

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

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SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

3. (Continued) The plan also must disclose:

1. Whether the plan departed from the guidelines used to develop the

medical necessity criteria;

2. The standards it uses to decide when to depart from these guidelines;

3. Whether the plan uses similar information and processes to develop

medical necessity criteria for medical/surgical benefits (including

information on whether treatment guidelines generally are used to

determine medical necessity for medical/surgical care and which

guidelines it uses); and

4. The criteria it uses to decide when to depart from the medical/surgical

guidelines.

This information also may include criteria related to medical

appropriateness, or whether the treatment is experimental or investigative. 

This may be the basis for various medical management standards, including

standards related to when your health care services have to be reviewed in

order for an ongoing course of treatment to continue to be covered

(concurrent review).

Note: Medical providers who contract with the plan to provide services will

still be able to request the plan’s medical necessity criteria under the Mental

Health Parity and Addiction Equity Act, regardless of whether they are acting

as an authorized representative.

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

8

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

4. I have a question about

the amount my plan

pays to an out-ofnetwork provider for

mental health and

substance use disorder

benefits. My plan

appears to pay less than

what they pay for my

out-of-network

medical/surgical

benefits. I am

concerned I will receive

a large bill.

Plan methods for determining what are called “usual, customary, and

reasonable charges” or other methods for determining payments to out-ofnetwork providers.

You can request information on what a plan pays to out-of-network providers

and whether these amounts are based on sources such as Medicare rates; a

schedule of “usual, customary and reasonable rates” developed by a third

party or the plan’s own, proprietary fee schedule. You can request

information about:

1. What percentage of these rates or fees the plan pays;

2. Whether the plan relies on the same rate or fee schedule and percentage

for out-of-network medical/surgical benefits;

3. Any modifications to the rate or fees when it comes to specific types of

mental health and substance use disorder providers (such as

psychologists or social workers); and

4. Whether any similar modifications are imposed on specific types of

medical/surgical benefits for specific providers and how they are

determined.

If the plan relies on its own fee schedule, you may request the studies,

schedules or similar documents that provide the basis for the payments to

providers. A plan or insurer cannot refuse to provide this information by

claiming it is proprietary.

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

9

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

5. I would like to know

what mental health and

substance use disorder

benefits and what

medical/surgical

benefits are subject to

preauthorization. My

plan says they are all

based on clinical

utilization review

guidelines.

Utilization review criteria related to both mental health and substance use

disorder and medical/surgical benefits provided under the plan or coverage. 

You can request the plan’s specific utilization review criteria, and other

materials, which could include:

1. Standards developed by an outside organization. Many health plans use

third-party standards to determine the level of care required by an

individual plan participant;

2. Criteria which may be developed by the issuer or third-party

administrator, for both mental health and substance use disorder

benefits and medical/surgical benefits;

3. Information on how the plan determines when it is appropriate to depart

from the criteria developed by an outside organization for both

medical/surgical and mental health and substance use disorder benefits

(if the plan departs from these criteria).

You can also request any analyses the plan has performed to verify whether

the plan complies with the Mental Health Parity and Addiction Equity Act.

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

10

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

6. My plan will not

authorize a treatment

recommended by my

health provider (in this

case, a specific

medication that was

prescribed). If

treatment is not

authorized, my plan will

not pay or will reduce

payment. 

The plan’s requirement for preauthorization, including utilization review

standards, and its medical criteria or “other evidentiary standards,

procedures, or strategies” used to develop its utilization review standards. 

To determine whether mental health and substance use disorder and

medical/surgical benefits are being provided comparably, you may request

information regarding the basis for determining what mental health and

substance use disorder and medical/surgical benefits are subject to utilization

review. This includes information about the medical guidelines, costs, or

other factors supporting the basis for the application of the utilization review

standard. This may include the following:

1. Medical necessity criteria (see scenario 3);

2. Utilization review standards (see scenario 5); and

3. Other factors related to imposing a utilization review requirement on a

particular mental health and substance use disorder benefit being sought,

such as cost or whether it is considered clinically effective. 

For example, plans and insurers often use reports of pharmacy and

therapeutics committees to decide how to cover prescription drug benefits. 

These reports should be requested in order to determine parity in

prescription drug benefits.

You also can request any analyses the plan has performed to verify whether

the plan complies with the Mental Health Parity and Addiction Equity Act.

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

11

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

7. I am seeking coverage

for services performed

by a mental health or

substance use disorder

provider. My primary

care doctor

recommends a

therapist with certain

licensure and training,

but my plan says that

such therapists are not

part of its network.

Standards for provider admission to participate in a network, including

reimbursement rates.

You can request information about the plan’s standards for admitting

providers to the network, such as the following:

1. The specific requirements for mental health and substance use disorder

providers to participate in the plan’s network (which could include

requirements based on degree, licensing, and/or supervised clinical

experience);

2. What these requirements are for providers of medical/surgical treatment;

and

3. The underlying reasons for certain requirements (such as supervised

clinical experience after a degree has been earned). 

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

12

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

8. My mental health or

substance use disorder

claim is being denied.

The reason for any denial of payment for services for mental health or

substance use disorder benefits.

The health plan or issuer must provide an adverse benefit determination

containing:

1. A specific reason for the denial;

2. Reference to the specific plan rules used to make the determination; and

3. A description of the plan’s appeal procedures.

The time for providing the notice will

vary based on the type of claim.

 For urgent care claims, the plan

must provide notice within 72

hours of when it received a claim.

 For pre-service claims (i.e., when a

service is denied before you

receive it), the plan must provide

notice within 15 days, with a onetime extension of 15 days allowed.

 For post-service claims (i.e., when

a payment for a service is denied

after you receive it), the plan must

provide notice within 30 days, with

a one-time extension of 15 days

allowed.

 For concurrent care claims, which

involve a determination to

continue, reduce or terminate your

current course of treatment

previously approved by the plan,

the plan must provide notice

sufficiently in advance of the

coverage termination date to allow

you to appeal. Additional rules

apply to decisions on requests you

make to extend an already

approved course of treatment.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

13

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

9. I am appealing my

plan’s denial of a

mental health or

substance use disorder

claim.

Copies of all documents, records, and other information relevant to your

claim for mental health or substance use disorder benefits.

The plan or issuer must provide all information relevant to the claim,

including information relevant to compliance with the Mental Health Parity

and Addiction Equity Act. If the denial is because you did not give the plan

enough information, a description will be provided of any additional material

necessary for the claimant to perfect the claim (i.e., provide the complete

information) with an explanation of why the information is necessary. In

addition, relevant information may include medical necessity criteria for

mental health and substance use disorder benefits and medical benefits (see

scenario 3) and rules about how treatment is limited and under what

conditions. This includes information on how non-quantitative treatment

limitations (e.g., preauthorization, medical management) are used for

benefits under the plan, and if a specific non-quantitative treatment

limitation was utilized in denying a claim.

This information could include:

1. Information about the underlying factors considered by the plan in

determining the application of a non-quantitative treatment limitation to

a benefit;

2. Comparable information related to application of the non-quantitative

treatment limitation to medical/surgical benefits;

3. The plan’s analysis in applying the plan requirement or limitation and all

documents used to develop the analysis for this requirement or

limitation; and

4. Any analyses the plan has performed, to verify whether the plan complies

with the Mental Health Parity and Addiction Equity Act. 

Upon request and free of charge, the

plan must give you reasonable access

to and copies of relevant documents,

records, and other information. The

plan must respond to your request

promptly but generally not later than

30 days after you make a request. 

Shorter time limits apply in the case of

urgent care claims.

 If your plan considers, relies upon,

or generates new or additional

evidence or reasons for denying

your benefit during your appeal,

this information should be

provided to you automatically with

sufficient time for you to respond.

NOTE: While you are entitled to

copies of all documents relevant to

your mental health or substance

use disorder claim, in some

instances, this request can result in

more information than you may

want. Talk to your plan about what

documents you wish to request,

and, if you prefer, how you can

receive the documents

electronically.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

14

SCENARIO

WHERE TO START?

SUGGESTIONS FOR INFORMATION THAT YOU HAVE A RIGHT TO THAT CAN

HELP

WHEN CAN I GET THESE DOCUMENTS?

10. My doctor ordered a

certain treatment, but

my plan denied my

claim. My plan said I

must try another, less

expensive treatment

first. My plan will only

consider my claim for

the treatment my

doctor ordered if the

less expensive

treatment does not

work.

Information on the plan’s “fail-first” policies or step therapy protocols.

To determine whether the plan’s mental health and substance use disorder

benefits and medical/surgical benefits are being provided comparably, you

can request information regarding the basis for determining which mental

health and substance use disorder benefits and medical/surgical benefits are

subject to “fail-first policies” or “step-therapy protocols.” “Fail-first” policies

or “step-therapy protocols” are plan medical management tools. The basis

may, for example, be the cost of treatment, medical guidelines, or a

combination of factors, but they need to be applied comparably across

mental health and substance use disorder benefits and medical/surgical

benefits. 

Promptly, but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.

11. I am being denied

payment by my plan

for a mental health or

substance use disorder

treatment (such as

intensive outpatient

therapy) because I

have not already

completed previously

prescribed treatment

which I stopped

against the medical

advice of my provider.

Exclusions based on failure to complete a course of treatment.

To determine whether the mental health and substance use disorder benefits

and medical/surgical benefits are being provided comparably, you may

request information regarding the basis for determining which mental health

and substance use disorder benefits and medical/surgical benefits are subject

to exclusions based on failure to complete a course of treatment. The basis

may be cost of treatment, medical guidelines, or a combination of factors, but

they need to be applied comparably across mental health and substance use

disorder benefits and medical/surgical benefits. 

Promptly but generally not later than

30 days after your request. Shorter

time limits apply in the case of urgent

care claims.
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration

U.S. Department of Labor, Employee Benefits Security Administration

15

Resources 

If you would like more information about the Mental Health Parity and Addiction Equity Act, there are a number of resources available to

help you understand where to go to get further assistance: 

1) To learn more about MHPAEA and your health plan’s compliance with parity, call or go to the following:

 U.S. Department of Labor Employee Benefits Security Administration (EBSA) web page has consumer information on

health plans. Or contact EBSA toll-free at: 1-866-444-3272 or through EBSA’s website at www.dol.gov/ebsa.

 U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Center for Consumer

Information & Insurance Oversight: 1-877-267-2323 ext. 61565

 Your state’s department of insurance website and contact information, which can be found on the National Association

of Insurance Commissioners website.

 The Substance Abuse and Mental Health Services Administration (SAMHSA) Implementation of the Mental Health

Parity and Addiction Equity Act (MHPAEA) web page.

o See in particular: Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits and Parity of

Mental Health and Substance Use Benefits with Other Benefits: Using Your Employer-Sponsored Health Plan to

Cover Services

2) To learn more about benefits and the appeals process, go to:

 The HealthCare.gov web page on health insurance rights and protections.

 EBSA’s web page Filing a Claim for Your Health or Disability Benefits
 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration 

U.S. Department of Labor, Employee Benefits Security Administration 

 

 

 

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Glossary of Terms
 

Term Acronym Description 

Affordable Care Act ACA Creates the Health Insurance Marketplaces, tax credits and Medicaid expansion to increase 

access to affordable coverage and provides protections for individual market health insurance 

and employment-based health coverage. Extends coverage of dependent children to age 26, 

prohibits preexisting condition exclusions, and prohibits lifetime and annual dollar limits on 

essential health benefits, among other consumer protections. 

Allowed Amount Maximum amount on which payment is based for covered health care services. This may be 

called “eligible expense,” “payment allowance," or “negotiated rate.” If your provider charges 

more than the allowed amount, you may have to pay the difference. 

Claim This term refers to your request for payment for mental health and substance use disorder or 

medical/surgical services to your health plan. This can also include your request for 

preauthorization. 

Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20 

percent) of the allowed amount for the service. You pay co-insurance plus any deductibles you 

owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 

and you’ve met your deductible, your co-insurance payment of 20 percent would be $20. The 

health insurance or plan pays the rest of the allowed amount. 

Concurrent Care claims Claims involving the continuation or extension of approved benefits or services to be provided 

over time or over a number of treatments (“concurrent care decisions”). A concurrent claim 

also includes a request for continued treatment beyond a course of treatment previously 

approved by the plan. 

16 
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Term Acronym Description 

Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you 

receive the service. The amount can vary by the type of covered health care service. 

Deductible The amount you owe for health care services that your health insurance or plan covers before 

your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan 

generally won’t pay anything until you’ve met your $1000 deductible for covered health care 

services subject to the deductible. The deductible may not apply to all services. 

Employee Retirement 

Income Security Act of 1974 

ERISA A federal law that offers protection for individuals enrolled in retirement, health, and other 

benefit plans sponsored by private-sector employers, employee organizations or both and 

provides rights to information and a required claims and appeals process for participants to get 

benefits from their plans. 

Financial Requirement 

(also referred to as “Cost 

Sharing”) 

FR Deductibles, copayments, coinsurance, or other out-of-pocket expenses. 

Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, 

disease, or its symptoms, and that meet accepted standards of medicine. 

Mental Health Parity and 

Addiction Equity Act of 2008 

MHPAEA A federal law that requires group health plans and insurers to treat limitations on mental health 

and substance use disorder benefits (such as copayments, visit limits, and preauthorization 

requirements) comparably to their coverage for general medical and surgical (medical/surgical) 

care. 

Non-quantitative Treatment 

Limitation 

NQTL Treatment limitations, including, but not limited to, geographic restrictions, restrictions on the 

types of facilities where services are covered, medical management, preauthorization, fail-first 

protocols, and prescription drug formularies. 

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Term Acronym Description 

Out-of-network Provider A provider who doesn’t have a contract with your plan to provide services. If your plan covers 

out-of-network services, you’ll usually pay more to see an out-of-network provider than a 

preferred (in-network) provider. Your plan or policy will explain what those costs may be. May 

also be called a “non-preferred provider” or “non-participating provider” instead of “out-ofnetwork provider.” 

Plan Document or 

Instrument 

These documents specify how the health plan is established or operated. The documents 

include the Summary Plan Description, trust agreement, and other written materials under 

which the plan is established or operated. 

Post-service Claims Claims for benefits that are not pre-service (meaning not approved prior to a service being 

delivered) or urgent care claims under your group health plan, including claims after medical 

services have been provided, such as requests for reimbursement or payment of the costs of the 

services provided. Most claims for group health benefits are post-service claims. 

Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription 

drug or durable medical equipment is medically necessary. Sometimes called prior 

authorization, prior approval or precertification. Your health insurance or plan might require 

preauthorization for certain services before you receive them, except in an emergency. 

Preauthorization isn’t a promise that your health insurance or plan will cover the cost. 

Pre-service Claims Requests for approval that the plan requires you to obtain before you get medical care, such as 

preauthorization or a decision on whether a treatment or procedure is medically necessary. 

Summary of Benefits and 

Coverage 

SBC An easy-to-read summary of costs and coverage of health plans. 

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Term Acronym Description 

Summary of Material 

Modifications 

SMMs Summarizes significant plan changes and corresponding changes in the information required to 

be in the Summary Plan Description. 

Summary Plan Description SPD Disclosure documents prepared by the plan that describe, in understandable terms, the rights, 

benefits, and responsibilities of participants and beneficiaries in ERISA-covered health benefit 

plans. The Summary Plan Description must include important information regarding the plan, 

such as information on how the plan works, eligibility requirements, what benefits the plan 

provides, and how those benefits may be obtained. 

Treatment Limitation Limits on benefits, including limits based on the frequency of treatment, number of visits, days 

of coverage, or other similar limits on the scope or duration of treatment. Examples include: 

outpatient visit limitations and inpatient day limits, as well as non-quantitative treatment 

limitations such as geographic restrictions, restrictions on the types of facilities where services 

are covered, utilization management, preauthorization, fail-first protocol, and prescription drug 

formularies. 

Urgent Care Claims A special kind of pre-service claim that requires a quicker decision because your health would be 

threatened if the plan took the normal time permitted to decide a pre-service claim. If a 

physician with knowledge of your medical condition tells the plan that a pre-service claim is 

urgent, the plan must treat it as an urgent care claim. 

Usual, Customary & 

Reasonable 

UCR The amount paid for a medical service in a geographic area based on what providers in the area 

usually charge for the same or similar medical service. The usual, customary and reasonable 

amount sometimes is used to determine the allowed amount. 

Utilization Review Utilization review requires that the plan, insurer, or an external panel of providers assess a 

course of treatment or services to determine if it is medically necessary and merits coverage, 

typically after or during the episode of care. 

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20

i MHPAEA applies to group plans with 51 or more employees of private companies or governmental employers and individual insurance coverage. Smaller plans

are generally subject to the parity provisions through the Affordable Care Act. For more information, see 78 FR 12834 (Feb. 25, 2013) (effective for plans years

beginning in 2014); 45 CFR 156.115, available at 78 FR 12834 (Feb. 25, 2013) (effective for plans years beginning in 2014).

ii See Employee Retirement Income Security Act (ERISA) sections 102, 104, 502, 503, and 712, as well as Public Health Service Act sections 2715 and 2719, as

incorporated in ERISA section 715 and implementing regulations at 29 CFR 2520.102-2, 2520.102-3, 2520.102-4, 2520.104b-1, 2520.104b-2, 2520.104b-3, 29

CFR 2560.503-1, 2590.712 (for mental health and substance use disorder benefits) 2590.715-2715 and 2590.715-2719. See also 78 FR 68240, 68247 (Nov. 13,

2013); Advisory Opinion 96-14A; Affordable Care Implementation FAQs, Part V, Q&A-10; Affordable Care Act Implementation FAQs, Part XVII, Q&A-8;

Affordable Care Act Implementation FAQs, part XXIX, Q12 & Q13; & Affordable Care Implementation FAQs, Part 31, Q&A-9, available at

https://www.dol.gov/ebsa/mentalhealthparity/ or https://www.cms.gov/cciio/resources/Fact-Sheets-and-FAQs/index.html.