Docket: EBSA-2009-0010 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Comment On: EBSA-2009-0010-0001 

Request for Information Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 

Equity Act of 2008 

Document: EBSA-2009-0010-DRAFT-0260 

Comment on FR Doc # E9-9629 

Submitter Information 

Name: Thomas Wilder 

Address: 

601 Pennsylvania Ave., NW 

South Building - Suite 500 

Washington, DC, 20004 

Email: twilder@ahip.org 

Phone: 202-778-3255 

Organization: America's Health Insurance Plans 

General Comment 

Attached are comments submitted on behalf of America's Health Insurance Plans 

in response to the Request for Information regarding the Paul Wellstone and Pete 

Domenici Mental Health Parity and Addiction Equity Act of 2008. 

Please contact me if you have any questions. 

Attachments 

PUBLIC SUBMISSION 

As of: May 29, 2009 

Received: May 28, 2009 

Status: Pending_Post 

Tracking No. 809bcd9f 

Comments Due: May 28, 2009

Submission Type: Web

EBSA-2009-0010-DRAFT-0260.1: Comment on FR Doc # E9-9629

EBSA-2009-0010-DRAFT-0260.2: Comment on FR Doc # E9-9629
May 28, 2009 

Submitted via the Federal eRulemaking Portal: www.regulations.gov

Attn: MHPAEA Comments 

Office of Health Plan Standards and Compliance Assistance 

Employee Benefits Security Administration 

Room N-5653 

U.S. Department of Labor 

200 Constitution Avenue, NW 

Washington, DC 20210 

Attn: CMS-4137-NC 

Centers for Medicare & Medicaid Services 

Department of Health and Human Services 

P.O. Box 8017 

Baltimore, MD 21244-8010 

CC:PA:LPD:PR (REG-120692-090) 

Room 5205 

Internal Revenue Service 

P.O. Box 7604 

Ben Franklin Station 

Washington, DC 20044 

Re: Request for Information Regarding the Paul Wellstone and 

Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 

74 Fed. Reg. 19155 (April 28, 2009) 

Dear Sir/Madam: 

America’s Health Insurance Plans (AHIP) is writing to offer comments and recommendations 

regarding implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (Pub. Law No. 110-343, the “MHPAEA”). We are responding to 

a Request for Information (RFI) published in the Federal Register on April 28, 2009 (74 Fed. 

Reg. 19155). AHIP strongly supported the MHPAEA and worked with a broad coalition of 

stakeholders in developing the legislation. 
May 28, 2009 

Page 2 

AHIP is the national association representing nearly 1,300 health insurance plans providing 

coverage to more than 200 million Americans. Our members offer a broad 

range of products in the commercial marketplace and also have demonstrated a strong 

commitment to participation in Medicare, Medicaid, and other public programs. 

We have attached the following materials in response to the RFI. 

• A discussion document addressing how mental health and substance use disorder benefits 

are currently covered by group health plans and group health insurers and offering 

recommendations on implementation of the new requirements (Attachment 1). 

• A draft set of “Frequently Asked Questions” on the MHPAEA that could be used to 

educate consumers, health care providers, employers, third-party administrators, and 

health insurance plans on the requirements of the MHPAEA (Attachment 2). 

• A chart outlining state insurance laws governing the provision of mental health and 

substance use disorder benefits (Attachment 3). 

AHIP’s recommendations for implementing the MHPAEA, as set out in the attached discussion 

document, address the following issues: 

• Application of the new requirements to group health plans and group health insurance. 

• Determining parity with respect to financial requirements and treatment limits between 

medical/surgical benefits and mental health/substance use disorder benefits. 

• Defining when the MHPAEA exclusion applies in the case of a small employer. 

• Disclosing information to consumers and health care providers on the application of 

medical necessity criteria. 

• Considering preemption of state parity requirements. 

AHIP and its member health insurance plans believe the MHPAEA will assure Americans 

greater access to behavioral health and substance use disorder coverage while continuing to 

promote high-quality, evidence-based care. We look forward to working with the federal 

agencies on this critical issue. 
May 28, 2009 

Page 3 

Please feel free to contact me at (202) 778-3255 or twilder@ahip.org if you have any questions. 

Sincerely, 

Thomas J. Wilder 

Senior Regulatory Counsel 

Attachments: 
1 

Attachment 1

America’s Health Insurance Plans 

Response to Request for Information 

Regarding the Paul Wellstone and Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008 

May 28, 2009 

America’s Health Insurance Plans (AHIP) is writing to provide the following comments 

and recommendations regarding implementation of the Paul Wellstone and Pete 

Domenici Mental Health Parity and Addiction Equity Act of 2008 (Pub. Law No. 110-

343, the “MHPAEA”). We are responding to a Request for Information (RFI) published 

in the Federal Register on April 28, 2009 (74 Fed. Reg. 19155). Our comments below 

discuss how coverage is currently provided by group health plans and group health 

insurance for mental health and substance use disorder benefits and provides 

recommendations with respect to implementation of the new requirements. 

Coverage for Mental Health and Substance Use Disorder Benefits 

Almost all individuals with employer-based health benefits have coverage for mental 

health and substance use disorder benefits. The most recent Kaiser Family 

Foundation/HRET Employer Health Benefits Survey indicates that 98% of covered 

workers have coverage for mental health benefits.1

 According to data from the U.S. 

Bureau of Labor Statistics, the number of employees with employer-provided coverage 

for alcohol and drug rehabilitation benefits ranged from 83% (for in-patient services) to 

87% (for out-patient services) in 2002, the last year for which data was available.2 

Over the past few years, health insurance plans have adopted a variety of approaches to 

coverage for mental health and substance use disorder benefits. For example, many 

health insurance plans provide case managers to coordinate medical, behavioral health, 

and social services needed by patients. In addition, health insurance plans promote 

access to a wide range of treatment settings including residential treatment facilities, 

partial hospitals, intensive-outpatient programs, and care provided through primary care 

physician offices.3

 

Coverage for mental health and substance use disorder benefits provided through health 

insurance is frequently based on state mandates. We have attached a chart outlining state 

requirements governing coverage of mental health and substance use disorder benefits 

 

1

 Kaiser Family Foundation/Health Research & Education Trust, Employer Health Benefits 2008 Annual 

Survey, available at: http://ehbs.kff.org/ 2

 John Morton and Patricia Aleman, Trends in Employer-Provided Mental Health and Substance Abuse 

Benefits, Monthly Labor Review (April 2005), available at: 

http://www.bls.gov/opub/mlr/2005/04/art3full.pdf 3

 These approaches are discussed more fully in a paper from the AHIP Center for Policy and Research, A 

New Generation of Behavioral Health Coverage: Perspectives from Interviews with Medical Leader (June 

2007), available at: http://www.ahipresearch.org/ 
2 

(Attachment 3). Forty-nine states have enacted mental health benefit mandate laws and 

forty states either include treatment for substance abuse benefits in such laws or have 

enacted separate requirements applicable to the group insurance market. These state laws 

impose significant requirements regarding the types of benefits that must be covered and 

the scope of financial requirements and treatment limits. 

Recommendations for Implementation of the MHPAEA 

Implementation of the parity requirements in the MHPAEA is a significant undertaking 

by group health plans and group health insurers. As discussed below, some group health 

plans and group health insurers have already begun negotiations for health benefits for 

the 2010 plan year or have finalized their contracts. As a result, it is important that 

implementation guidance be released as soon as practicable, to be followed by 

regulations. We offer the following recommendations for guidance and regulations with 

respect to implementation of the new requirements. 

A. Streamlining Implementation of the MHPAEA

Issue A1: Provide clear and concise guidance to assist consumers, health care providers, 

employers, third-party administrators, and health insurance plans with understanding the 

MHPAEA requirements. 

Discussion A1: The MHPAEA is effective for most group health plans and group health 

insurance for plan years that begin on or after October 3, 2009.4 Many health insurance 

plans are already in negotiation with employers for health coverage that will begin after 

the MHPAEA effective date and, in some cases, those contracts are finalized. Health 

insurers are in the process of submitting insurance policy changes to comply with the 

MHPAEA requirements to state regulatory agencies for approval. 

As a result of the on-going negotiations between employers and health insurance plans 

and the time needed to obtain state regulatory approvals for insurance policy changes, it 

is critical that guidance be provided in a timely manner for consumers, health care 

providers, employers, third-party administrators, and health insurance plans. We 

recommend that guidance in the form of “frequently asked questions” (FAQs) be released 

first to address the priority issues with respect to the MHPAEA, followed by proposed 

rules allowing sufficient time for public comment. The guidance and regulations from 

the Centers for Medicare & Medicaid Services (CMS), the Employee Benefits Security 

Administration (EBSA), and the Internal Revenue Service (IRS) on the 1996 Mental 

Health Parity Act provide a good framework for future regulatory activity (See: Tres. 

Reg. §54.9812-IT, 29 C.F.R. §2590.712, and 45 C.F.R. §146.136). 

The guidance and regulations should provide clear and concise information on the 

application of the MHPAEA and include examples of different scenarios with respect to 

 

4

 In the case of group health plans maintained pursuant to one or more collective bargaining agreements, 

the MHPAEA is effective for plan years beginning after the latter of: (a) January 1, 2010; or (b) the date on 

which the last collective bargaining agreement relating to the plan terminates. 
3 

the application of financial requirements and treatment limits. We have attached a draft 

set of FAQs (Attachment 2) that may serve as an outline for the initial guidance on 

implementation of the MHPAEA. 

AHIP recommends that guidance, in the form of frequently asked questions, should 

be released as soon as practicable to assist the effective implementation of the 

MHPAEA, followed by proposed regulations with a comment period. The guidance 

and regulations should provide clear and concise information for consumers, health 

care providers, employers, third-party administrators, and health insurance plans 

on the MHPAEA requirements. 

Issue A2: Provide compliance-based enforcement in situations where good faith efforts 

have been made to implement the MHPAEA. 

Discussion A2: As noted, there may be cases where group health plans and group health 

insurers have already established contracts for health benefits for plan years beginning on 

or after October 3, 2009. These agreements may be based on insurance policies approved 

by state insurance regulators. Given the complexity of the MHPAEA requirements, 

CMS, EBSA, and IRS should work with group health plans and group health insurers to 

bring them into compliance with the MHPAEA. We believe compliance-based 

enforcement is appropriate when group health plans and group health insurers are 

working in good-faith to implement the new requirements. 

A similar approach to enforcement was taken by the U.S. Department of Health and 

Human Services’ Office for Civil Rights (OCR) during the initial period after adoption of 

the privacy rule promulgated under the Health Insurance Portability and Accountability 

Act (HIPAA).5

 OCR recognized that the new rules, which govern the collection, use, and 

disclosure of protected health information by health care providers, health plans, and 

health care clearinghouses, raised a number of significant and complex administrative 

issues for regulated entities. As a result, OCR determined that assisting covered entities 

with their compliance responsibilities was a more effective means of enforcement than 

assessing fines. 

We are not asking CMS, EBSA or IRS to forgo their oversight responsibilities. However, 

we recommend that the regulatory agencies take into consideration that group health 

plans and group health insurers are working diligently and in good faith to provide health 

coverage in full compliance with the MHPAEA in the absence of guidance on many 

critical issues. 

AHIP recommends that CMS, EBSA, and IRS adopt a compliance based approach 

to enforcement of the MHPAEA and that the agencies work with group health plans 

and group health insurers on implementation of the requirements. Group health 

plans and group health insurers that are working in good faith to comply with the 

MHPAEA should not be penalized during the first year after the effective date of 

the legislation. 

 

5

 45 C.F.R. Parts 160 and 164. 
4 

Issue A3. Allow group health plans and group health insurers to meet their obligations to 

provide information to consumers about medical necessity criteria through compliance 

with existing ERISA requirements. 

Discussion A3: The MHPAEA requires group health plans and group health 

insurance to provide certain types of information to consumers and health care 

providers: 

Availability of Plan Information – The criteria for medical necessity 

determinations made under the plan with respect to mental health or 

substance use disorder benefits (or the health insurance coverage offered 

in connection with the plan with respect to such benefits) shall be made 

available by the plan administrator (or the health insurance issuer offering 

such coverage) in accordance with regulations to any current or potential 

participant, beneficiary, or contracting provider upon request. The reason 

for any denial under the plan (or coverage) or reimbursement or payment 

for services with respect to mental health or substance use disorder 

benefits in the case of any participant or beneficiary shall, on request or as 

otherwise required, be made available by the plan administrator (or the 

health insurance issuer offering such coverage) to the participant or 

beneficiary in accordance with regulations. 

(29 U.S.C. §1185a(a)(4) and 42 U.S.C. §300gg-5(a)(4) as amended by Pub. Law No. 

110-343). 

Group health plans are subject to extensive disclosure requirements under ERISA 

including requirements governing the disclosure of information to participants and 

beneficiaries when enrolled in a plan. Plans must provide participants and beneficiaries 

with a summary plan description (SPD) including a description of benefits provided 

under the plan, any cost-sharing requirements, descriptions of providers and provider 

networks, and “any provisions requiring preauthorizations or utilization review as a 

condition to obtaining a benefit or service under the plan.” (29 C.F.R. §2520.102-3(j)(3)). 

In addition, group health plans are required by the ERISA claims rule to provide the 

following information to participants and beneficiaries: 

In the case of an adverse benefit determination by a group health plan or a 

plan providing disability benefits, 

(A) If an internal rule, guideline, protocol, or other similar criterion 

was relied upon in making the adverse determination, either the specific 

rule, guideline, protocol, or other similar criterion; or a statement that such 

a rule, guideline, protocol, or other similar criterion was relied upon in 

making the adverse determination and that a copy of such rule, guideline, 
5 

protocol, or other criterion will be provided free of charge to the claimant 

upon request; or 

(B) If the adverse benefit determination is based on a medical necessity 

or experimental treatment or similar exclusion or limit, either an 

explanation of the scientific or clinical judgment for the determination, 

applying the terms of the plan to the claimant’s medical circumstances, or 

a statement that such explanation will be provided free of charge upon 

request. 

(29 C.F.R. §2560.503-1(g)(v)). 

We believe the MHPAEA requirements to inform participants and beneficiaries 

regarding medical necessity criteria under the plan are met when a group health 

plan complies with the ERISA requirements to provide the SPD and to provide 

information in the case of an adverse benefit determination. 

AHIP recommends that guidance and regulations clarify that group health 

plans and group health insurers are in compliance with the MHPAEA 

requirements to inform participants and beneficiaries regarding the use of 

any medical necessity criteria by following the ERISA rules for providing 

SPDs and for informing individuals concerning an adverse benefit 

determination. 

B. Establishing the Framework for Applying the MHPAEA 

Issue B1: Clarify the group health plans and group and individual health insurance that 

are subject to the MHPAEA. 

Discussion B1: As discussed, the MHPAEA applies to group health plans and group 

health insurers subject to ERISA and the PHSA. Clear guidance should be provided to 

define which group health plans (and health insurers offering coverage to group health 

plans) are required to comply with the MHPAEA. This guidance should expand on the 

information currently available from CMS and EBSA with respect to the application of 

the 1996 Parity Act to certain entities. We have included a chart at the end of this 

discussion document outlining the application of the MHPAEA to group health plans and 

group and individual health insurance. 

AHIP recommends that guidance be provided to define the application of the 

MHPAEA to group health plans and group and individual health insurers. 

Issue B2: Clarify that group health plans that offer benefits only for retirees are not 

subject to the MHPAEA. 

Discussion B2: ERISA, IRC, and the PHSA exempts the application of the MHPAEA in 

the case of “any group health plan (and health insurance coverage offered in connection 
6 

with a group health plan) for any plan year if, on the first day of such plan year, such plan 

has less than 2 participants who are current employees . . . .” (See: 26 U.S.C. 

§9831(a)(2), 29 U.S.C. §1191a(a), and 42 U.S.C. §300gg-21(a)). 

In some limited situations, an employer that offers health coverage to retired employees 

and to their family members may choose to establish a separate group health plan to 

provide such benefits. Because these group health plans have fewer than 2 participants 

who are current employees, the plan (and any health insurance offered to such plan) is not 

subject to the MHPAEA. 

AHIP recommends that guidance be provided to clarify that a “retiree-only” group 

health plan that has fewer than 2 participants who are current employees is not 

subject to the MHPAEA. 

Issue B3: Provide clear definitions to determine if an employer has 50 or fewer 

employees on an annual basis. 

Discussion B3: The 1996 Parity Act exempts employers that employ between 2 and 50 

employees on an annual basis. This requirement was modified by the MHPAEA to also 

exempt employers with one employee in those states that recognize “groups of one” for 

purposes of group health insurance laws. 

The current rules establish requirements to determine when an employer is employing 

between 2 and 50 employees on an annual basis and are therefore exempt from the parity 

requirements. This rule should be retained with a modification to include the changes for 

employers with one employee.6

AHIP recommends that guidance and regulations provide a clear definition to 

determine if an employer has between 1 and 50 employees on an annual basis. The 

current rule should be retained with a modification to include employers with one 

employee. 

Issue B4: Clarify whether employee assistance programs (EAPs) are governed by the 

MHPAEA. 

Discussion B4: Employee assistance programs (EAPs) are established by employers to 

provide a variety of ancillary services to employees and their family members including 

legal advice, financial planning, wellness promotion, and counseling. In some cases, 

these services may be used to address behavioral health or substance abuse issues. It is 

not entirely clear whether EAPs would meet the ERISA definition of a group health plan. 

We believe that in most cases, even if the EAP is considered to be a group health plan, 

the EAP does not provide medical and surgical benefits and, as a result, is not subject to 

the MHPAEA. 

 

 

6

 See: Tres. Reg. §54.9812-IT, 29 C.F.R. §2590.712, and 45 C.F.R. §146.136. 
7 

AHIP recommends that guidance and regulations define the situations (if any) 

under which an EAP would fall under the definition of a “group health plan” for 

purposes of the MHPAEA. The guidance and regulations should also clarify that if 

the EAP is a group health plan, it must provide mental health or substance use 

disorder benefits and medical and surgical benefits in order to be subject to the 

parity requirements. 

Issue B5: Clarify the application of the preemption provision. 

Discussion B5: The MHPAEA preempts state parity requirements applicable to 

group health insurance in some situations. The preemption provisions are 

included in the 1996 Mental Health Parity Act which amended HIPAA: 

(1) In general 

Subject to paragraph (2) and except as provided in subsection (b) of this 

section [regarding portability of insurance coverage], this part shall not be 

construed to supersede any provision of State law which establishes, 

implements, or continues in effect any standard or requirements solely 

relating to health insurance issuers in connection with group health 

insurance coverage except to the extent that such standard or requirement 

prevents the application of a requirement of this part. 

(2) Continued preemption with respect to group health plans. 

Nothing in this part shall be construed to affect or modify the provisions 

of section 1144 of this title with respect to group health plans. 

(29 U.S.C. §1191(a)). 

The MHPAEA preempts state laws that “prevent the application” of the federal parity 

requirements. In addition, the preemption provision recognizes the general principle that 

states may not regulate ERISA group health plans. 

AHIP recommends that guidance and regulations clarify that state laws applicable 

to group health insurance are preempted if they prevent the application of the 

federal parity requirements in the MHPAEA and that states may not regulate group 

health plans. 

C. Determining Parity With Respect to Financial Requirements and Treatment 

Limits 

Issue C1. Clarifying that group health plans and health insurance issuers may impose 

separate financial requirements and treatment limits with respect to medical and surgical 

benefits and mental health or substance use disorder benefits. 
8 

Discussion C1: The MHPAEA sets out the following requirements with respect to parity 

between medical and surgical benefits and mental health or substance use disorder 

benefits: 

(A) In General – In the case of a group health plan (or health insurance 

coverage ordered in connection with such a plan) that provides both 

medical and surgical benefits and mental health or substance use disorder 

benefits, such plan or coverage shall ensure that -- 

(i) the financial requirements applicable to such mental health or 

substance use disorder benefits are no more restrictive than the 

predominant financial requirements applied to substantially all medical 

and surgical benefits covered by the plan (or coverage), and there are no 

separate cost sharing requirements that are applicable only with respect to 

mental health or substance use disorder benefits; and 

(ii) the treatment limitations applicable to such mental health or 

substance use disorder benefits are no more restrictive than the 

predominant treatment limitations applied to substantially all medical and 

surgical benefits covered by the plan (or coverage) and there are no 

separate treatment limitations that are applicable only with respect to 

mental health or substance use disorder benefits. 

(29 U.S.C. §1185a(a)(3) and 42 U.S.C. §300gg-5(a)(3) as amended by Pub. Law 

No. 110-343). 

A “financial requirement” is defined in the MHPAEA as including deductibles, 

copayments, coinsurance or out-of-pocket expenses. A financial requirement 

does not include an annual or lifetime dollar limit on benefits covered by the 1996 

Parity Act. A “treatment limitation” is defined by the MHPAEA as a limit on the 

frequency of treatments, number of visits, days of coverage or other similar limits. 

The MHPAEA is intended to provide patients with access to mental health or 

substance abuse disorder benefits on the same basis as coverage for medical and 

surgical benefits with respect to any applicable financial requirements or 

treatment limits. There are a number of approaches to reaching this goal: 

• A group health plan or group health insurer could choose not to impose 

any financial requirements or treatment limits. 

• Financial requirements or treatment limits could be applied by the group 

health plan or group health insurer only to medical and surgical benefits 

and not to mental health or substance use disorder benefits. 

• The financial requirements or treatment limits applied to mental health or 

substance use disorder benefits could be the same as or more favorable to 
9 

the patient than the financial requirements or treatment limits applied to 

medical and surgical benefits. For example, the group health plan or 

group health insurer could choose to impose a $1,000 annual deductible 

for medical and surgical benefits and a $500 annual deductible for mental 

health benefits. 

The MHPAEA clearly recognizes that a group health plan or group health insurer 

may impose separate financial requirements or treatment limits to medical and 

surgical benefits and to mental health or substance use disorder benefits: 

(i) the financial requirements applicable to such mental health or 

substance use disorder benefits are no more restrictive than the 

predominant financial requirements applied to substantially all 

medical and surgical benefits covered by the plan (or coverage), 

and there are no separate cost sharing requirements that are 

applicable only with respect to mental health or substance use 

disorder benefits; and 

(ii) the treatment limitations applicable to such mental health or 

substance use disorder benefits are no more restrictive than the 

predominant treatment limitations applied to substantially all 

medical and surgical benefits covered by the plan (or coverage) 

and there are no separate treatment limitations that are applicable 

only with respect to mental health or substance use disorder 

benefits. 

(29 U.S.C. §1185a(a)(3) and 42 U.S.C. §300gg-5(a)(3) as amended by Pub. Law 

No. 110-343, emphasis added). 

The provisions state that a group health plan or group health insurer cannot impose “more 

restrictive” financial requirements or treatment limits for mental health or substance use 

disorder benefits. In addition, the MHPAEA states that if there is a financial requirement 

or treatment limit with respect to mental health or substance use disorder benefits, there 

must be a similar (or “more restrictive”) requirement or limit for medical and surgical 

benefits (e.g., a plan cannot impose a $25 copayment for visits to a psychologist and not 

impose a copayment for a clinician providing medical or surgical services).7

In addition, permitting separate financial requirements or treatment limits for medical and 

surgical benefits and for mental health or substance use disorder services may allow 

patients to access mental health or substance use disorder benefits sooner in some cases. 

For example, a group health plan or group health insurer could choose to impose an 

 

7

 The Office of Personnel Management has notified health insurance plans providing coverage through the 

Federal Employees Health Benefits (FEHB) program that separate financial requirements may be applied to 

medical/surgical benefits and to mental health and substance use disorders (although the OPM strongly 

encourages FEHB plans to offer combined deductibles). See: FEHB Program Carrier Letter 2009-08 

(April 20, 2009). 
10 

overall $1,000 deductible and once the patient meets the deductible he or she may access 

any services covered by the health coverage or insurance. As an alternative, the group 

health plan or group health insurer could impose a $500 deductible for medical and 

surgical services and a separate $500 or lower deductible for mental health or substance 

use disorder services. In the latter case, a patient who needs to access mental health 

services will do so sooner because of the separate $500 deductible applied to those 

treatments. 

Allowing separate financial requirements and treatment limits is also easier to administer 

for those group health plans and group health insurance issuers that choose to “carve out” 

mental health or substance use disorder services through a third-party vendor. Group 

health plans and health insurers may choose to carve-out these services because of the 

specialized expertise of the vendor in providing services for addressing behavioral health 

conditions or substance use disorders In many cases the third-party vendor does not 

coordinate the administration of health care claims with the medical and surgical benefits 

and, as a result, it would be very difficult to determine when a patient has met a “global” 

deductible or treatment limit applicable to medical and surgical benefits and mental 

health or substance use disorder benefits. 

We believe that group health plans and group health insurance are permitted (but not 

required) to impose separate financial requirements and treatment limits with respect to 

medical and surgical benefits and for mental health or substance use disorder benefits. 

AHIP recommends that guidance be provided to clarify that a group health plan or 

group health insurer may impose separate financial requirements and treatment 

limits with respect to medical and surgical benefits and for mental health or 

substance use disorder benefits. 

Issue C2. Define the term “substantially all” for purposes of determining parity between 

medical and surgical benefits and mental health and substance use disorder benefits. 

Discussion C2: As noted, the MHPAEA requires group health plans and group health 

insurers to determine parity by comparing financial requirements and treatment 

limitations applied to mental health or substance use disorder benefits to the 

“predominate” financial requirement or treatment limit “applied to substantially all 

medical and surgical benefits covered by the plan (or coverage . . . .” (29 U.S.C. 

§1185a(a)(5) and 42 U.S.C. §300gg-5(a)(5) as amended by Pub. Law No. 110-343). 

The term “substantially all” is not defined in the MHPAEA. We believe there are 

different approaches that a group health plan or group health insurer could take to 

determine if a financial requirement or treatment limitation is “substantial” with respect 

to medical and surgical benefits including a calculation of the number (or dollar value) of 

claims or an actuarial value of the benefits to which a particular financial requirement or 

treatment limit are applied. We believe that group health plans and group health insurers 

may use any reasonable method to determine whether a financial requirement or 

treatment limitation is applicable to substantially all medical and surgical benefits. 
11 

AHIP recommends that guidance and regulations clarify that a group health plan or 

group health insurer may use any reasonable method to determine when a financial 

requirement or treatment limitation is applicable to substantially all medical and 

surgical benefits including an analysis of the number (or dollar value) or claims or 

the actuarial value of the benefits to which the financial requirements or treatment 

limits are applied. 

Issue C3: Permit the determination of parity based on a comparison of inpatient 

services, outpatient services, in-network providers, and out-of-network providers.

Discussion C3: As discussed above, parity is determined under the MHPAEA on the 

basis of the “predominant” financial requirements or treatment limits applied to 

“substantially all medical and surgical benefits covered by the plan (or coverage) . . . .” 

Making such a determination depends on a variety of factors such as the different types 

of services or providers that are covered, the number of co-payment or co-insurance 

categories, and whether services are categorized as medical, surgical, mental health, or 

substance use disorder. 

We believe it is appropriate to construct a general framework for making parity 

comparisons for financial requirements and treatment limits between different benefit 

categories. One comparison, involving in-network and out-of-network coverage, is 

explicitly recognized by the MHPAEA: 

In the case of a plan or coverage that provides both medical and surgical 

benefits and mental health or substance use disorder benefits, if the plan or 

coverage provides coverage for medical or surgical benefits provided by 

out-of-network providers, the plan or coverage shall provide coverage for 

mental health or substance use disorder benefits provided by out-ofnetwork providers in a manner that is consistent with the requirements of 

this section. 

(29 U.S.C. §1185a(a)(5) and 42 U.S.C. §300gg-5(a)(5) as amended by Pub. Law 

No. 110-343). This statutory language contemplates that the financial 

requirements and treatment limits applied to out-of-network medical and surgical 

benefits shall be consistent (i.e., at “parity”) with out-of-network coverage for 

mental health or substance use disorder benefits. 

We believe the same rule should be applied in comparing inpatient and outpatient 

benefits. The determination of parity should compare inpatient medical and 

surgical benefits with inpatient mental health and substance use disorder benefits. 

Likewise, the determination of parity with respect to outpatient medical and 

surgical benefits should be in comparison with the coverage for outpatient mental 

health or substance use disorder benefits. 
12 

AHIP recommends that guidance and regulations clarify that parity may 

based on a comparison of: (a) inpatient medical and surgical benefits to 

inpatient mental health and substance use disorder benefits; (b) outpatient 

medical and surgical benefits to outpatient mental health and substance use 

disorder benefits; (c) in-network medical and surgical benefits to in-network 

mental health and substance use disorder benefits; and (d) out-of-network 

medical and surgical benefits to out-of-network mental health and substance 

use disorder benefits. 

Issue C4. Clarify that the MHPAEA does not mandate that group health plans and group 

health insurance cover any mental health conditions or substance use disorders, services, 

treatments or settings of care. 

Discussion C4: The MHPAEA is intended to provide parity with respect to financial 

requirements and treatment limits. The new requirements do not mandate that group 

health plans or group health insurance provide coverage for any specific types of mental 

health conditions or substance use disorders, types of services or treatments, or settings of 

care.8

The MHPAEA addresses parity with respect to financial requirements and 

treatment limits. As noted above, “financial requirements” are defined as 

including “deductibles, copayments, coinsurance, and out-of-pocket expenses.” 

Treatment limits are defined as including “limits on the frequency of treatment, 

number of visits, days of coverage, or other similar limits on the scope or duration

of treatment.” (29 U.S.C. §1185a(a)(3)(B) and 42 U.S.C. §300gg-5(a)(3)(B) as 

amended by Pub. Law No. 110-343, emphasis added). In this context, treatment 

limits applies to limits on the number of days of treatment or number of office 

visits that are covered (or similar limits) and is not intended to require the group 

health plan or group health insurer to cover all treatments or settings of care for a 

particular mental health condition or substance use disorder covered under the 

terms or conditions of the plan or benefits. 

In addition, the MHPAEA makes clear that, except for the parity requirements, 

nothing in the Act is intended to affect “the terms and conditions of the plan or 

coverage relating to such benefits . . . .” (29 U.S.C. §1185a(b) and 42 U.S.C. 

§300gg-5(b) as amended by Pub. Law No. 110-343). The MHPAEA provisions 

indicate a clear understanding that group health plans and group health insurers 

may determine what conditions, treatments, services, or settings of care are 

covered under the terms and conditions of the plan or insurance policy.9

 

8

 As discussed above, there are requirements with respect to coverage for out-of-network services for 

mental health and substance use disorder benefits if the group health plan or group health insurer provides 

coverage for out-of-network medical and surgical services. 9

 As noted above and in Attachment 3, a significant number of states impose requirements for the coverage 

of mental health and substance use disorder services. 
13 

This position is supported by the legislative history of the MHPAEA. The Senate 

Committee Report includes the following statement with respect to the application 

of the parity requirements: 

The bill would not require plans to offer mental health benefits, nor would 

it require that those plans cover all types of mental health services or 

ailments if the plan covered any mental health services or ailments. 

(Sen. Rep. No. 110-53, 110th Cong., 1st Session (2007) at p. 7). The House Energy and 

Commerce Committee Report includes similar language: 

In addition, this requirement does not change the current ability of an 

insurer or provider to determine medically necessary and appropriate care 

and treatment for their patients. It merely ensures that patients are not 

denied mental health coverage based on the specific disorder they have. 

For example, a person cannot be denied coverage by their health plan 

merely because they have autism. A plan may determine, however, 

whether a treatment is medically necessary or appropriate for a given 

person at a given time based on their individual situation. 

(H. Rep. 110-374, Part 3, 110th Cong., 2nd Session (2008)).10

We believe the MHPAEA is not intended to require group health plans or group health 

insurance to cover any specific mental health condition or substance use disorder, 

services or treatments, or settings of care (other than the requirement to provide coverage 

for out-of-network benefits, discussed above). 

AHIP recommends that guidance and regulations clarify that the MHPAEA 

does not impose any obligation on a group health plan or group health 

insurer to cover any specific mental health conditions or substance use 

disorders, services or treatments, or settings of care (except for out-ofnetwork benefits in certain cases). 

Issue C5: Clarify that treatment limitations subject to the MHPAEA do not 

include prior authorization, utilization review, or other processes used to provide 

appropriate medical management. 

Discussion C5: As discussed, the MHPAEA requires group health plans and 

group health insurers to apply parity between medical and surgical benefits and 

mental health or substance use disorder benefits with respect to treatment 

limitations. Treatment limitations are defined as including “limits on the 

frequency of treatment, number of visits, days of coverage, or other similar limits

 

10 The version of H.R. 1424 approved by the Energy and Commerce Committee and discussed in the 

Committee Report included a requirement that group health plans and group health insurers cover all 

conditions in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This requirement was not 

included in the final version of the legislation. 
14 

on the scope or duration of treatment.” (29 U.S.C. §1185a(a)(3)(B) and 42 U.S.C. 

§300gg-5(a)(3)(B) as amended by Pub. Law No. 110-343, emphasis added). 

We believe treatment limitations do not include efforts by a group health plan or 

group health insurer to make decisions regarding coverage for appropriate care for 

an individual including utilization review, prior-authorization, and other medical 

management techniques. As used in the MHPAEA, treatment limitations only 

applies with respect to limits on days of coverage, or number of visits, or other 

“similar” limits. 

AHIP recommends that guidance and regulations clarify that group health 

plans and group health insurers are permitted to use appropriate techniques 

to make decisions regarding coverage including utilization review, prior 

authorization, and other medical management. 

Issue C6: Allow Medicaid managed care organizations (MCOs) to take into 

consideration whether there are additional “wrap-around” services provided by 

the state Medicaid program in the determination of parity with respect to 

treatment limits. Provide additional guidance to state Medicaid agencies on the 

application of the MHPAEA to Medicaid and CHIP MCOs. 

Discussion C6: The MHPAEA applies to Medicaid MCOs if a State chooses to cover 

mental health or substance use disorder benefits through the Medicaid health plan. (See: 

42 U.S.C. §1396u-2 (b)(8) and BBA State Managed Care Letter, January 20, 1998 from 

the Health Care Financing Administration). All states provide behavioral health services 

for Medicaid beneficiaries and most provide coverage for some substance use disorder 

benefits. States have taken a variety of approaches for such coverage -- the state 

Medicaid program may offer behavioral health benefits through a “carve-out” with a 

third-party vendor, contract with a MCO to provide some or all of the services, or give 

beneficiaries access to services through community mental health centers. In some cases 

the state will provide services directly or through the MCO based on the type of patient 

(e.g., “serious” behavioral health conditions are provided through state community health 

centers and the MCO provides all other mental health benefits).11

A unique situation has arisen in a handful of states where the Medicaid MCO is 

responsible for providing a set level of care – for example, up to 30 days for inpatient 

treatment for behavioral health conditions. After the 30 day treatment limit has been 

reached, the state Medicaid program agrees to cover any additional benefits needed by 

the beneficiary. In these cases the 30 day inpatient treatment limit through the MCO may 

be contrary to the MHPAEA unless there is a similar treatment limit under the MCO for 

medical and surgical services. However, the beneficiary will have access to additional 

in-patient services through the state Medicaid program. 

 

11 See: American Public Health Services Association and National Association of State Medicaid Directors, 

Serving the Needs of Medicaid Enrollees with Integrated Behavioral Health Services in Safety Net Primary 

Care Settings, April 18, 2008, available at: 

http://www.aphsa.org/home/doc/IntegratedMentalHealthHRSA.pdf 
15 

We believe that Medicaid MCOs should be given the flexibility to structure the provision 

of mental health and substance use disorder benefits such that the determination of any 

treatment limits may take into account whether any additional services are available 

through the Medicaid program once such limits are reached. 

In addition, Medicaid and CHIP MCOs have contracts with state Medicaid agencies 

which determine the benefits, operations, and process for each program and plans must 

wait for individual state implementation guidance on any changes to the financial 

requirements or treatment limitations. An MCO cannot unilaterally change the financial 

requirements or treatment limitations without a notification and approval from the state 

which may, in turn, be bound by legislative or regulatory requirements imposed on the 

program. 

AHIP recommends CMS should provide guidance to clarify that a Medicaid MCO 

may take into consideration whether additional services are available to the 

beneficiary through the state when determining parity with respect to treatment 

limits applicable to mental health or substance use disorder services. In addition, 

CMS should provide guidance to state Medicaid programs regarding the 

application of the MHPAEA requirements to Medicaid and CHIP MCOs. 
16 

GROUP HEALTH PLANS AND HEALTH INSURANCE ISSUERS SUBJECT TO 

THE MENTAL HEALTH PARITY ACT 

Type of Product/Coverage Subject to the Mental Health Parity Act?

ERISA Group Health Plans Yes. See: 26 U.S.C. §9812, 29 U.S.C. 

§1185a, and 42 U.S.C. §300gg-5 as 

amended by the Paul Wellstone and Pete 

Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (Pub. L. No. 

110-343). Small employers (companies 

with 50 or fewer employees) are exempt. 

Group Health Insurance Yes. See: 26 U.S.C. §9812, 29 U.S.C. 

§1185a, and 42 U.S.C. §300gg-5 as 

amended by the Paul Wellstone and Pete 

Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (Pub. L. No. 

110-343). Small employers (companies 

with 50 or fewer employees) are exempt. 

Individual Health Insurance No. See: 26 U.S.C. §9812, 29 U.S.C. 

§1185a, and 42 U.S.C. §300gg-5 as 

amended by the Paul Wellstone and Pete 

Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (Pub. L. No. 

110-343). 

Disability Income Insurance, Long-Term 

Care Insurance, Medicare Supplement 

Insurance, and Supplemental Insurance 

No. Insurance that provides “excepted 

benefits” to group health plans are not 

subject to the Mental Health Parity Act of 

1996 or the Mental Health Parity and 

Addiction Equity Act of 2008.. See: 26 

U.S.C. §9832, 29 U.S.C. §1191h, and 42 

U.S.C. §300gg-91. 

Medicare Advantage Plans The law applies to Medicare Advantage 

plans offered through an ERISA group 

health plan. See: 26 U.S.C. §9812, 29 

U.S.C. §1185a, and 42 U.S.C. §300gg-5 as 

amended by the Paul Wellstone and Pete 

Domenici Mental Health Parity and 

Addiction Equity Act of 2008 (Pub. L. No. 

110-343). Small employers (companies 

with 50 or fewer employees) are exempt. 
17 

Type of Product/Coverage Subject to the Mental Health Parity Act?

The law does not apply to a “stand-alone” 

Medicare Advantage plan. Retiree-only 

plans are not included in the definition of 

group health plans under ERISA. See: 26 

U.S.C. §9831(a)(2), 29 U.S.C. § 1191a(a), 

and 42 U.S.C. §1191a. 

Medicaid Health Plans Yes. The law applies to Medicaid managed 

care plans, if a State chooses to cover 

mental health or substance use disorder 

benefits through the Medicaid health plan. 

See: 42 U.S.C. §1396u-2 (b)(8) and BBA 

State Managed Care Letter, January 20, 

1998, Health Care Financing 

Administration. 

State Children’s Health Insurance Program Yes. See: 42 U.S.C. §1397cc (f)(2) as 

amended by Section 582 of the Children’s 

Health Insurance Program Reauthorization 

Act of 2009 (Pub. Law No. 111-3. 

Federal Employees Health Benefits Plans Yes. The Office of Personnel Management 

has imposed contracting requirements for 

FEHB that follow the Mental Health Parity 

Act of 1996and the Paul Wellstone and 

Pete Domenici Mental Health Parity and 

Addiction Equity Act of 2008. See: FEHB 

Program Carrier Letter No. 2000-17 (April 

11, 2000), Program Carrier Letter No. 

2008-17 (November 10, 2008), and 

Program Carrier Letter No. 2009-08 (April 

20, 2009).. 

State and Local Government Employee 

Plans 

A self-funded non-federal governmental 

plan is subject to the Mental Health Parity 

Act unless the governmental plan chooses 

to be exempt from such requirements. A 

health insurance carrier that offers 

coverage to a non-federal governmental 

plan is subject to the Mental Health Parity 

Act unless. See: 42 U.S.C. §300gg-21 

(b)(2)(A).
1 

Attachment 2

FREQUENTLY ASKED QUESTIONS ABOUT THE PAUL WELLSTONE AND 

PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY 

ACT OF 2008 

The “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act 

of 2008” was signed into law on October 3, 2008 (Pub. L. No. 110-343). The Act 

amended the Mental Health Parity Act of 1996 and requires that certain group health 

plans and group health insurance apply the same treatment limits and financial 

requirements to medical and surgical benefits and to mental health and substance use 

disorder benefits. 

The following “Frequently Asked Questions” (FAQs) provide an overview of the key 

provisions of this new law and the 1996 law. As used in these FAQs the term 

“MHPA” applies to the Mental Health Parity Act of 1996 as amended by the Paul 

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 

2008. 

1. What types of health coverage are subject to the MHPA? 

The MHPA applies to certain group health plans and health insurance issuers that offer 

coverage in connection with a group health plan to the extent that such group health plans 

or health insurance issuers provide mental health and/or substance use disorder benefits. 

As discussed below, the MHPA may apply in certain situations to Medicare Advantage 

coverage offered through a group health plan, Medicaid and State Children’s Health 

Insurance Programs (CHIP) coverage, and state and local government plans. 

2. What types of benefits are subject to the parity requirements of the MHPA? 

The MHPA applies to benefits with respect to services for mental health conditions and 

substance use disorders as defined under the terms of the plan or group health insurance 

coverage and in accordance with applicable Federal and State law. 

3. Does the MHPA require group health plans or group health insurance to cover 

mental health or substance use disorder benefits? 

No. The MHPA does not require group health plans or health insurance issuers to 

provide coverage for mental health or substance use disorder benefits. Health insurance 

issuers may, however, be subject to State laws that require the insurer to offer or provide 

coverage for mental health or substance use disorder benefits. 
2 

4. Does the MHPA require group health plans or group health insurance to provide 

any specific treatments, services or settings of care for a mental health condition or 

substance use disorder? 

No. The MHPA requirement only applies to any mental health and/or substance use 

disorder benefits that may be offered by a group health plan or health insurance issuer. 

The MHPA does not require a group health plan or health insurance issuer to cover any 

specific treatments, services or settings of care for a covered mental health and/or 

substance use disorder benefit. See question No. 17 below regarding coverage for out-ofnetwork providers. 

 

5. Are all employers subject to the new law? 

The MHPA does not apply to a “small employer.” A small employer is defined in the 

MHPA as an employer who employed an average of at least 2 but not more than 50 

employees on business days during the preceding calendar year and who employed at 

least 2 employees on the first day of the plan year. A small employer also includes an 

employer with one employee in states that apply group insurance laws to “groups of 

one.” 

6. How do you determine the size of an employer? 

For purposes of determining whether an employer is a “small employer” the following 

rules apply: 

(a) All persons treated as a single employer under subsections (b), (c), (m), and (o) of 

section 414 of the Internal Revenue Code of 1986 (26 U.S.C. §414) are treated as one 

employer. 

(b) If an employer was not in existence throughout the preceding calendar year, the 

determination of whether the employer is a “small employer” is based on the average 

number of employees the employer reasonably expects to employ on business days 

during the current calendar year. 

(c) Any reference to an employer as a “small employer” includes a reference to a 

predecessor of the employer. 

7. Are Medicaid managed care plans subject to the MHPA? 

Yes. Medicaid managed care plans that offer mental health or substance use disorder 

benefits are required to comply with the MHPA insofar as such requirements apply and 

are effective with respect to a health insurance issuer that offers group health insurance 

coverage (See: 42 U.S.C. §1396u-2 (b)(8)). Medicaid managed care plans have contracts 

with state Medicaid agencies which determine the benefits, operations, and process for 

each program and plans must wait for individual state implementation guidance on any 

changes to the financial requirements or treatment limitations. 
3 

8. Does the MHPA apply to State Children’s Health Insurance Programs (CHIP)? 

Yes. A State Children’s Health Insurance Program must comply with the MHPA insofar 

as such requirements apply with respect to a health insurance issuer that offers group 

health insurance coverage (See: 42 U.S.C. §1397cc (f)(2) as amended by Section 502 of 

the “Children’s Health Insurance Program Reauthorization Act of 2009” (Pub. Law No. 

111-3)). CHIP managed care plans have contracts with state Medicaid agencies which 

determine the benefits, operations, and process for each program and plans must wait for 

individual state implementation guidance on any changes to the financial requirements or 

treatment limitations. 

9. Do Medicare Advantage plans have to comply with the MHPA? 

The MHPA applies to coverage under a Medicare Advantage plan that is offered through 

a group health plan, provided that the plan is not offered by a small employer. The 

MHPA does not apply if the Medicare Advantage plan is offered through a separate 

group health plan that is offered only to retirees and that has fewer than 2 participants 

who are current employees (See: 26 U.S.C. §9831(a), 29 U.S.C. §1191a(a), and 42 

U.S.C. §300gg-21(a)). 

10. Does the law apply to health insurance sold in the individual market? 

No. The MHPA does not apply to health insurance coverage sold in the individual 

market. 

11. Does the MHPA apply to disability insurance, long-term care insurance, 

Medicare supplemental insurance, or other supplemental coverage? 

No. Health insurance issuers that provide “excepted benefits” to group health plans (such 

as disability income insurance and long-term care and Medicare supplemental insurance 

coverage that is offered separately) are not subject to the MHPA (See: 26 U.S.C. §9832, 

29 U.S.C. §1191b, and 42 U.S.C. §300gg-91). 

12. Are self-funded non-federal governmental plans subject to the MHPA? 

The MHPA applies to self-funded non-federal governmental plans unless they choose to 

be exempt from the MHPA (see: 42 U.S.C. §300gg-21 (b)(2)(A)). The MHPA does 

apply to health insurance coverage provided to a non-federal governmental plan. 

13. How does the MHPA govern the provision of mental health or substance use 

disorder benefits? 

In general, the MHPA requires group health plans and health insurance issuers that 

provide coverage to a group health plan to apply annual and lifetime dollar limits, 

financial requirements, and treatment limits for mental health or substance use disorder 
4 

benefits on the same or better basis as such requirements are applied to medical and 

surgical benefits. 

14. How does the MHPA apply to annual and lifetime dollar limits? 

A group health plan or group health insurance that provides coverage for medical and 

surgical benefits and mental health or substance use disorder benefits that includes an 

aggregate annual or lifetime dollar limit on substantially all medical and surgical benefits 

that may be paid under the plan or health insurance must either: 

• not apply any annual or lifetime limits to any benefits; 

• apply the same annual or lifetime dollar limits to the mental health benefits and/or 

substance use disorder benefits; or 

• apply aggregate annual or lifetime dollar limits for mental medical and surgical 

benefits that are lower than the dollar limits applied to mental health or substance 

use disorder benefits. 

Example 1

A group health plan that provides coverage for medical and surgical benefits and mental 

health or substance use disorder benefits is in compliance with the MHPA if it does any 

of the following: 

• Does not have an aggregate annual dollar limit on any benefits. 

• Has a $500,000 combined aggregate annual dollar limit on all benefits 

(medical/surgical, mental health, and substance use disorders). 

• Has a $500,000 aggregate annual dollar limit for medical/surgical benefits, and a 

$500,000 or greater aggregate annual dollar limit (or no dollar limit) for mental 

health benefits and substance use disorder benefits. 

Example 2

A group health plan that provides coverage for medical and surgical benefits and mental 

health or substance use disorder benefits on an inpatient and outpatient basis is in 

compliance with the MHPA if it does any of the following: 

• Does not have an aggregate annual dollar limit on any benefits. 

• Has a $500,000 combined aggregate annual dollar limit on all benefits provided 

on an outpatient basis (medical, surgical, mental health, and substance use 

disorders) and a $500,000 combined aggregate annual dollar limit on all benefits 

provided on an inpatient basis (medical, surgical, mental health, and substance use 

disorders). 
5 

• Has the following annual aggregate dollar limits: 

- $500,000 for inpatient medical and surgical benefits; 

- $500,000 for outpatient medical and surgical benefits; 

- $500,000 or greater limits (or no limits) for inpatient mental health 

and/or substance use disorder benefits; and 

- $500,000 or greater limits (or no limits) for outpatient mental health 

and/or substance use disorder benefits. 

 

15. How does the MHPA apply to financial requirements? 

The financial requirements applied to mental health or substance use disorder benefits 

must not be more restrictive than the predominant financial requirements applied to 

substantially all medical and surgical benefits. In addition, a group health insurance plan 

or group health insurer may not apply a separate financial requirement to mental health or 

substance use disorder benefits that is not applicable to medical and surgical benefits. 

Financial requirements include deductibles, copayments, coinsurance, and out-of-pocket 

expenses but do not include annual or lifetime dollar limits. A financial requirement is 

“predominant” if it is the most common or frequent type of such requirement. 

Example 1

A group health plan or group health insurance that provides coverage for medical and 

surgical benefits and mental health or substance use disorder benefits is in compliance 

with the MHPA if it does any of the following: 

• Does not apply any copayment requirements. 

• Applies a $20 copayment requirement for any patient visit to a health care 

provider regardless of the type of benefits (medical, surgical, mental health or 

substance use disorders). 

• Applies a $20 copayment requirement for any patient visit to a health care 

provider in connection with a medical or surgical benefit and a $20 or lower 

copayment requirement (or no co-payment requirement) for any visit to a health 

care provider in connection with a mental health or substance use disorder benefit. 

Example 2

A group health plan that provides coverage for medical and surgical benefits and mental 

health or substance use disorder benefits is in compliance with the MHPA if it does any 

of the following: 

• Does not apply any annual deductible requirements for any benefits. 
6 

• Applies a $1,000 combined annual deductible applicable to all benefits (medical, 

surgical, mental health or substance use disorders). 

• Applies a $1,000 annual deductible for medical and surgical benefits and a $1,000 

or lower annual deductible (or no deductible) for mental health benefits or 

substance use disorder benefits. 

Example 3

A group health plan that provides coverage for medical and surgical and mental health or 

substance use disorder benefits is in compliance with the MHPA if it does any of the 

following: 

• Does not apply any annual coinsurance requirements. 

• Applies an annual 5% coinsurance requirement to all benefits (medical, surgical, 

mental health or substance use disorders). 

• Applies an annual 5% coinsurance requirement for medical and surgical benefits 

and a 5% or lower annual coinsurance requirement (or no coinsurance 

requirement) for mental health or substance use disorder benefits. 

• Applies the following requirements: 

- 10% coinsurance for inpatient medical and surgical benefits; 

- 5% coinsurance for outpatient medical and surgical benefits; 

- 10% or lower coinsurance (or no coinsurance) for inpatient mental 

health or substance use disorder benefits; and 

- 5% or lower coinsurance (or no coinsurance) for outpatient mental 

health and substance use disorder benefits. 

16. How does the MHPA apply to treatment limitations? 

The treatment limitations applied to mental health or substance use disorder benefits must 

not be more restrictive than the predominant treatment limitations applied to substantially 

all medical and surgical benefits. In addition, a group health plan or group health insurer 

may not apply a separate treatment limit to mental health or substance use disorder 

benefits that is not applicable to medical and surgical benefits. 

“Treatment limitations” are defined as including limits on the frequency of treatment, 

number of visits, or days of coverage or other similar limits on the scope or duration of 

treatment. A treatment limit is “predominant” if it is the most common or frequent type 

of such limit. 
7 

Example 1

A group health plan that provides coverage for medical and surgical benefits and mental 

health or substance use disorder benefits is in compliance with the MHPA if it does any 

of the following: 

• Does not apply annual limits on the number of treatments that are covered. 

• Limits coverage on an annual basis to 30 visits to a health care provider regardless 

of the type of benefits (medical/surgical, mental health, or substance use 

disorders). 

• Limits coverage on an annual basis to 30 visits to a health care provider in 

connection with a medical or surgical benefit and 20 or more visits (or no limits) 

to a health care provider in connection with mental health or substance use 

disorder benefits. 

 

Example 2

A group health plan that provides coverage for mental health and substance use disorder 

benefits is in compliance with the MHPA if it does any of the following: 

• Does not apply annual limits on the number of days that will be covered for 

inpatient treatment regardless of the type of benefits (medical, surgical, mental 

health or substance use disorders). 

• Limits coverage to 50 days of inpatient treatment each year regardless of the type 

of benefits (medical, surgical, mental health or substance use disorders). 

• Limits to 30 days each year for inpatient treatment in connection with a medical 

or surgical benefit and 30 or more days (or has no limits) for inpatient treatment 

in connection with mental health or substance use disorder benefits. 

17. Does the MHPA require group health plans and group health insurance to 

cover out-of-network services? 

Group health plans and group health insurance that covers out-of-network services for 

medical and surgical benefits must cover out-of-network services for mental health or 

substance use disorder benefits (if the group health plan or group health insurance 

otherwise covers mental health or substance use disorder benefits). The financial 

requirements or treatment limits applicable to out-of-network coverage for medical and 

surgical benefits are compared to the financial requirements or treatment limits applicable 

to out-of-network coverage for mental health and/or substance use disorder benefits. 
8 

Example 1

A group health plan or group health insurance that provides coverage for medical and 

surgical benefits and mental health or substance use disorder benefits is in compliance 

with the MHPA if it does any of the following: 

• Requires patients to pay a $20 co-payment for any office visit to an in-network 

provider regardless of the type of benefit (medical, surgical, mental health or 

substance use disorder) and requires patients to pay 20% co-insurance for any 

services provided by an out-of-network provider regardless of the type of benefit 

(medical, surgical, mental health or substance use disorder). 

• Does not apply any day treatment limits for network inpatient services but limits 

coverage on the number of days covered by an out-of-network inpatient facility 

regardless of the type of benefits (medical, surgical, mental health or substance 

use disorder). 

• Limits treatments for an out-of-network medical or surgical in-patient facility to 

20 days, limits treatments for an out-of-network mental health inpatient facility to 

30 days, and does not apply any treatment limits for an out-of-network substance 

use disorder facility. 

18. How does the cost exemption work? 

Group health plans and group health insurers may be exempted from the mental health 

parity requirements under certain situations. This exemption only applies for subsequent 

plan years – in other words, the plan or insurer must comply with the parity requirements 

for at least one plan year and the exemption must be based on actual claims data. 

A group health plan or group health insurer that demonstrate that the application of the 

parity requirements has increased the actual total costs of coverage for all benefits that 

are provided (medical/surgical, mental health, and substance use disorder) by more than 

2% for the first plan year (1% for subsequent plan years) is exempted for the following 

plan year. The determination may be made based on actual claim costs incurred during 

the first six months of the plan year. 

The determination of an increase in costs must be made in a written report by a qualified 

and licensed actuary who is a member in good standing of the American Academy of 

Actuaries. The group health plan or group health insurer must maintain the actuary’s 

report and any underlying documentation for six years. 

Plans or insurers claiming the increased cost exemption must notify the appropriate 

government agency and the plan participants and beneficiaries 30 days before the 

exemption becomes effective. 
9 

19. Does the MHPA prohibit group health plans or group health insurers from 

applying utilization review or medical necessity criteria or other policies to 

encourage appropriate and effective care? 

The MHPA states that nothing in the Act, except for the requirement to provide parity in 

the application of financial and treatment limits or requirements, shall affect “the terms 

and conditions of the plan or coverage . . . .” As a result, group health plans and group 

health insurers are not restricted from applying utilization review, medical necessity 

determinations or other policies to encourage appropriate and effective care. 

20. Are group health plans and group health insurers required to make information 

about their coverage for mental health or substance use disorder benefits available 

to enrollees or to health care providers? 

Group health plans and group health insurers must provide the criteria used for medical 

necessity determinations applicable to coverage for mental health or substance use 

disorder benefits to any current or potential participant, beneficiary or contracting 

provider upon request. In addition, the plan or insurer must give participants and 

beneficiaries the reason for any denial of reimbursement or payment for mental health 

and substance use disorder benefits on request. Group health plans and group health 

insurers are required by existing rules under the Employee Retirement Income Security 

Act (ERISA) to provide such information as part of the Summary Plan Description given 

to participants and beneficiaries and in response to a denial of a claim for benefits. 

21. Who is responsible for enforcing the requirements of the new law?

The Department of Labor is responsible for enforcing the provisions of the MHPA with 

respect to group health plans. The Department of Health and Human Services will 

enforce the requirements applicable to group health insurers. The Treasury Department 

enforces the Internal Revenue Code penalties for noncompliance. 

22. What are the penalties for non-compliance with the MHPA? 

In addition to any enforcement actions that may be taken under ERISA or the PHSA, a 

health insurance plan that violates the Act is subject to an excise tax of $100 per day for 

each day of noncompliance (See: 26 USC §4980D). 

23. Does the Act preempt state laws? 

In general, a group health plan and a health insurance issuer that provides coverage to a 

group health plan must comply with the MHPA. Health insurance issuers may also be 

subject to state laws that regulate or require insurers to offer or to cover mental health 

and/or substance use disorder benefits. 

The MHPA preempts any state law that “prevents the application” of the Federal 

requirements (See: 29 U.S.C. §1191 (a)(1) and 42 U.S.C. §300gg-23 (a)(1)). In general, 
10 

this means that a state law is preempted if it is impossible for the health insurer to comply 

with both the state requirements and the MHPA. 

The MHPA does not change the ERISA provisions that preempt any state laws that affect 

group health and welfare benefit plans (See: 29 U.S.C. §1191 (a)(2) and 42 U.S.C. 

§300gg-23 (a)(2)). 

24. When do the provisions of the MHPA go into effect? 

The requirements of the new law are effective for plan years beginning on or after one 

year from the date the legislation was signed into law (October 3, 2008). As a result, the 

provisions apply to new contracts and renewals on or after October 3, 2009. 

In the case of group health plans maintained pursuant to one or more collective 

bargaining agreements, the MHPA is effective for plan years beginning after the latter of: 

(a) January 1, 2010 or (b) the date on which the last collective bargaining agreement 

relating to the plan terminates.1

 

1

 As noted, the effective date for collectively bargained plans was amended by Pub. L. No. 110-460. 
© America’s Health Insurance Plans. All rights reserved 

Mental Health and Substance Abuse Coverage and Parity: 

Summary of Federal and State Requirements 

(as of May 28, 2009) 

History: In September 1996, Congress enacted legislation (P.L. 104-204), the Mental Health Parity Act (MHPA), requiring group health plans that offer mental health coverage benefits to apply the same aggregate lifetime dollar limits and annual dollar limits to mental health coverage as those applied to coverage of other services. 

 Since the law was enacted, it continued to be reauthorized annually and was most recently reauthorized in 2007 until December 31, 2008. 

• On October 3, 2008, Congress enacted the “Paul Wellstone and 

Pete Domenici Mental Health Parity and Addiction Equity Act of 2008”, otherwise known as the “Mental Health Parity Act” (P.L. No. 110-343). Generally, this act requires group health plans and insurers to apply the same treatment and financial limits to medical and surgical benefits and to mental health and substance use disorder benefits.  These new requirements are effective October 3, 2009. 

• On November 10, 2008 the Office of Personnel Management 

(OPM) issued a letter (No. 2008-17) explicitly applying the 

“Mental Health Parity Act” requirements to the Federal Employees Health Benefits Program (FEHBP). On April 20, 2009, OPM issued a subsequent letter (No. 2009-08) requiring all 

FEHBP carriers, starting January 1, 2010, to offer parity benefits for medical and surgical benefits and mental health or substance use benefits, including out-of-network benefits. 

Approaches1

: Forty-nine states (AL, AK, A

FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, MMS, MO, MT, NE, NV, NH, NJ, NM, NY, NPA, RI, SC, SD, TN, TX, UT, VT, VA, WAenacted mental health benefit mandate laws. There are three basic approaches states have mental health or substance abuse coverage la

 benefits must be covered; benefits must be offered; and/or 

 benefits must be covered on a parity 

surgical, or physical illnesses. 

• Some states combine these approaches a

approaches within the state (e.g. differenon group size, different requirements for grams, etc). 

Coverage Mandate: Thirty-eight states (AR, IA, KS, LA, ME, MD, MA, MI, MN, MS, MNM, NY, NC, ND, OH, OK, OR, PA, RI, SCWV, and WI) impose mandatory coverage rhealth benefits. 

1 A state may appear in more than one category b

 have more than one mental health statute.
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 2 Mandated Offer: Thirteen states (AL, CA, CO, FL, GA, IL, KY, MS, MO, SC, TX, UT, and WA) impose offering requirements. • Mandated offer requirements do not mandate coverage, but require that coverage be offered to the employer or individual, and, 

if those benefits are purchased, then they must be provided in a certain way. 

Parity: Forty-two states (AK, AZ, AR, CA (parity with coverage for 

brain disorders), CO, CT, DE, GA, ID, IN, IL, IA, KS, KY, LA, ME, MD, MA, MI, MN, MO, MT, NE, NH, NJ, NY, NM, NC, ND, OH, OK, OR, PA, RI, SC, SD, TX, UT, VT, VA, WA, and WV) require parity between coverage of mental health and coverage for physical 

illnesses. • Some states apply the requirement for parity only to annual and 

lifetime dollar limits, while others apply the parity requirement more broadly. 

Definition of Mental Illness: Definitions of mental illness vary from state to state and some states provide different definitions within their own mental health laws. • Seventeen states (AR, CT, FL, GA, HI, KS, KY, MO, NE, NH, 

NC, RI, SC, TN, UT, VT, and WA) define mental illness as any conditions defined in the most recent version of the Diagnostic 

and Statistical Manual of Mental Disorders (DSM), the International Classifications of Diseases (ICD), and/or other standard nomenclature. 

• Twenty-six states (AL, CA, CO, DE, HI, ID, IL, IA, LA, ME, 

MA, MO, MT, NE, NV, NH, NJ, NY, OH, OK, PA, SC, SD, TX, VA, and WV) define mental illness through a specified list of disorders (e.g., schizophrenia, bipolar disorder, major depression, panic disorder, and obsessive-compulsive disorder). 

• Eighteen states (AK, AZ, AR, CA, CO, MD, MI, MN, MS, MT, 

NJ, ND, OH, OR, TN, VA, WA, and WI) do not define the term “mental illness.” 

• Five states (IN, KS, NM, NY, and SC) define mental illness 

through reference to the definitions or other terms of the health benefit plan, contract, certificate, or policy documents. 

Substance Abuse Benefits: Twenty-two stateKS, KY, ME, MD, MA, MI, MN, MO, MT, VT, VA, and WI) either explicitly include, oinclude, coverage for substance abuse within • Twenty-nine states (AL, AK, AR, CA, C

ME, MA, MI, MN, MS, MO, NE, NV, NPA, SD, TN, UT, WA and WV) have se

coverage laws. 

Exemption for cost increases: Fourteen state

MI, MS, MO, NV, NM, OH, OK, TN, and Wwhich provide an exemption from the manda

viding the coverage increases costs by a cert

• Five states (AL, ID, KY, NM, and NY) 

tion, but require a study or report on the dated benefit, including the costs associaerage. 

2009 legislative activity: To date, three statenacted legislation expanding their current m• AR amended its existing mental health p

things, incorporate a specific reference ters and to modify the cost exemption pro

• KS expanded its mental health coverage 

drug abuse and substance abuse disorder

• MT modified its severe mental illness co

porate a coverage requirement for autism

Chart: The following chart highlights key pmental health coverage law and catalogs curand substance abuse laws. • This document does not include informa

autism benefit mandates. For informatioplease see the AHIP Autism Spectrum DState Requirements chart.
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 3 

State law Applicability Definitions Major provisions 

Federal Law 29 USCA §§511, 512, and 712; 42 USCA §2705; and 26 USCA §9812 (P.L. No. 110-343) Effective 10/3/09

Group health plans and group health insurers that provide coverage to group health plans; Medicaid health plans; and CHIP. Does not apply to insurers that provide “excepted benefits” to group health plans, such as disability income, long-term care, and Medicare supplemental coverage that is offered separately. Does not apply to small employers (2-50 employees), including companies in states that apply to “groups of one.” 

“Mental health benefits” means 

benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable federal and state law. “Substance use disorder benefits”means benefits with respect to services for substance use disorders, as defined under the terms of the plan and in accordance with applicable federal and state law. “Financial requirement” are defined as including deductibles, copayments, coinsurance, and outof-pocket expenses. “Treatment limitations” are defined as including limits on the frequency of treatment, number of visits, or days of coverage or other similar limits on the scope or duration of treatment. 

Mental health and substance abuse parity requireme

coverage of mental health or substance use disorder bene

• Prohibits financial requirements applied to mental h

order benefits from being more restrictive than the pquirements applied to substantially all medical/surg

Scope of coverage: To the extent an affected entity incllifetime financial or treatment limit on substantially all mfits, requires the entity to apply the same applicable limisubstance use disorder benefits; or not include such limistance use disorders that are less than the limits applied fits. 

• Prohibits affected entities from applying a separate 

mental health or substance use disorder benefits thacal/surgical benefits. 

• Prohibits treatment limitations applied to mental hea

order benefits from being more restrictive than the ptations applied to substantially all medical/surgical b

• Prohibits affected entities from applying a separate 

health or substance use disorder benefits that is not cal/surgical benefits. 

Benefit management: Allows affected entities to apply necessity determinations, or other tools to encourage appHowever, requires parity in the application of financial aother requirements that affect the terms and conditions o

• Requires affected entities to provide the criteria use

terminations applicable to coverage for mental healtbenefits to any current or potential participant, benevider upon request. 

Out-of-network services: Requires the entity to provide for mental health and substance use disorders to the exteis provided for medical/surgical benefits. Exemption for cost increases: Exempts affected entitiements, if after their initial year of complying with the law
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 4 

State law Applicability Definitions Major provisions 

that the application of the parity requirements has increacoverage for medical/surgical benefits and mental health order benefits by more than 2% for the first plan year anyears. • Requires the determination of an increase in cost to 

qualified and licensed actuary who is a member in gican Academy of Actuaries. 

• Requires affected entities to promptly notify the Sec

(depending on agency oversight) and any appropriaall participants and beneficiaries of its exemption. 

Penalties: Imposes an excise tax of $100/per day for eacPreemption: Follows the HIPPA standard for preemptiolaw that “prevents the application of” the federal requirestate law if the health insurer is unable to comply with band the federal parity requirements. 

Alabama Ala. Code §27-20A-1, et. seq.Effective 1979 

Group, blanket, franchise or association health insurance policies providing coverage on an expense incurred basis; group, blanket, franchise or association service or indemnity contracts issued by nonprofit corporations; group-type self insurance plans; and HMOs. 

“Alcoholism” means a chronic disorder or illness in which the individual is unable, for psychological or physical reasons, or both, to refrain from the frequent consumption of alcohol in quantities sufficient to produce intoxication and, ultimately, injury to health and effective functioning. 

Substance abuse mandated offer requirements: Requing alcoholism treatment to provide benefits to any insurconnection with the treatment of alcoholism when such tlicensed doctor. Scope of coverage: Requires benefits offered to include residential treatment rendered at a state licensed hospital residential alcoholism treatment or detoxification facility• Requires benefits to include a minimum of 30 days 

equivalent per calendar year. 

• Uses a formula to compute equivalency which equa

short-term residential alcoholism treatment facility t

ment and which equates 3 sessions of outpatient treaor an alcoholism treatment facility to 1 day of inpat

Alabama Ala. Code §27-54.1, et. seq. 

Group health benefit plans. Does not apply to plans 

“Mental illness” means the following: • schizophrenia; • schizophrenia form disorder; 

Mental health mandated offer requirements: Requirebenefits for the treatment and diagnosis of mental illnesstions that are no less extensive than the benefits provided physical illnesses. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 5 

State law Applicability Definitions Major provisions 

Effective 2001 covering employers 

with 50 or fewer employees. 

• schizoaffective disorder; • bipolar disorder; • panic disorder; • obsessive-compulsive disorder; • major depressive disorder; • anxiety disorders; • mood disorders; and • any condition or disorder involving mental illness, excluding alcohol and substance abuse, that falls under 

any of the ICD diagnostic categories. 

• Requires affected entities to offer to provide, at a m

treatment, and outpatient services for a person suffenervous condition. 

Scope of coverage: Permits affected entities to include pfor maximum benefits and coinsurance and limitations, dutilization review consistent with state law. • Requires reasonable efforts to be made to include a 

fied providers to insure reasonable access to service

Benefit management: Requires, at the request of the pla

to furnish data substantiating that initial or continued tresary and appropriate. • Requires the insurer or other issuer of the group hea

same criteria for medical treatment of mental illness for physical illness under the same contract when mdetermination. 

• Clarifies that affected entities may continue to estab

criteria and utilization protocols for mental health psignation of types of providers for which coverage identialing criteria used in the selection of providers

Out-of-network services: Does not require coverage of are not covered or participating in an affected entity’s neCost report: Requires affected entities to provide an annsurance Commissioner. • Requires such report to include certification of parit

and total annual costs of mental health services rela

• Requires the Commissioner to compile this data for 

an annual report solely for the purpose of demonstraof these requirements. 

Rules of construction: Provides that the requirements squire coverage and benefits for the treatment of alcoholidencies through the diagnosis of a mental illness. 

Alaska Health care insurance “Large employer” means an em- Mental health parity requirements: Does not mandate 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 6 

State law Applicability Definitions Major provisions 

Alaska Stat. §§21.54.151 and 21.54.500 Effective 2006 

plans providing medical/surgical and mental health benefits sold to large employers. 

ployer that employed an average of at least 51 employees on the business days during the preceding calendar year and that employs at least 2 employees on the first day of a health benefit plan year. 

illness or conditions. • Prohibits financial requirements applied to mental h

more restrictive than those applied to medical/surgic

Scope of coverage: Prohibits plans that do not include a

annual limit on substantially all medical/surgical benefitgate lifetime or annual limit on mental health benefits. • Requires plans that include an aggregate lifetime an

stantially all medical/surgical benefits to:  include the mental health benefits within the ag

nual limit without distinguishing between the libenefits and mental health benefits; or 

 provide an aggregate lifetime and/or annual lim

fits that is not less than the limit for medical/su

• Requires plans that include different aggregate lifeti

ferent categories of medical/surgical benefits to pro

limits on mental health benefits consistent with fede

• Requires plans that include different annual limits o

ries of medical/surgical benefits to provide for annubenefits consistent with federal law. 

Benefit management: Does not affect the terms and conamount, duration, or scope of mental health benefits undmental health benefits, including cost sharing, limits on days of coverage, and requirements relating to medical nExemption for cost increases: Exempts a plan from the application such requirements would result in an increasof at least 1%. 

Alaska Alaska Stat. §21.42.365 Effective 1997 

Health care insurers. Does not apply to insurers providing coverage for less than five employees or fraternal benefit societies. 

“Alcoholism or drug abuse”means an illness characterized by: • a physiological or psychological dependency, or both, on 

alcoholic beverages of controlled substances; or 

• habitual lack of self-control 

in using alcoholic beverages 

Substance abuse coverage requirements: Requires affhealth care insurance plan (except for catastrophic insurafor treatment of alcoholism or drug abuse. • Requires insurers to offer benefits to employers with 

Scope of coverage: Requires benefits to be at least $9,6efit years and include lifetime benefits of at least $19,20

amounts every 3 years consistent with CPI. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 7 

State law Applicability Definitions Major provisions 

 or controlled substances to 

the extent that the person’s health is substantially impaired or the person’s social or economic function is substantially disrupted. 

• Prohibits affected entities from: 

 requiring different deductibles and co-pays for 

than for another covered illness; 

 using a different claim payment methodology in 

alcoholism or drug abuse than that used in deteanother covered illness; 

 requiring different pre-notification of treatment 

coholism and drug abuse than for other covered 

 limiting coverage with provisions not applicabl

nesses, including pre-existing illnesses; 

 limiting treatment to either an inpatient or outp excluding from coverage the cost of medically 

cluding medical or psychiatric evaluation, activcounseling, or prescription drugs or supplies retreatment facility; or 

 denying reimbursement for actual services rend

ment was interrupted or not completed. 

Arizona Ariz. Rev. Stat. §20-2322 Effective 1998

Group health plans and issuers. Does not apply to small employers (2-50 employees). 

No definitions. However, stipulates that mental health services or mental health benefits do not include benefits for the treatment of substance abuse or chemical dependency. 

Mental health parity requirements: Does not mandate illness or conditions. However, to the extent benefits are comply with the below requirements. Scope of coverage: Prohibits affected entities that provihealth benefits from imposing different aggregate annualar limits for mental health benefits than for medical/sur• Requires a plan’s aggregate annual or aggregate life

to both medical/surgical benefits and mental health 

Benefit management: Permits affected entities providin

impose terms and conditions in relation to the amount, dage for such services or benefits under the plan, includinlimits on the number of visits or days of coverage; and rmedical necessity. Exemption for cost increases: Relieves a plan of compthese services and benefits increases costs to the plan by 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 8 

State law Applicability Definitions Major provisions 

Arkansas Ark. Code Ann. §23-86-113 Effective 1983 

Blanket and group accident and health policies and contracts of hospital and medical service corporations. 

No definitions. Mental health coverage requirements: Requires affect

pitalization or medical benefits to provide inpatient, outplization for mental illness. • Requires affected entities providing mental health c

for the payment of services rendered by licensed pro

 If the offer is accepted, provides that the amoun

same limits in the policy for mental health cove

Scope of coverage: Permits affected entities to establish inpatient, partial hospitalization, or outpatient care, even 

ferent from the co-pay for any other covered condition o• Prohibits affected entities from imposing limits on b

amounts, lifetime maximum payments, payments foments per day of partial hospitalization which differ conditions or illnesses. 

• Requires policies to small employers (50 employees 

nual maximum benefit payable of no less than $7,50

• Permits policies sold to employers with 51 or more 

annual maximum of 8 inpatient or partial hospitaliztient visits. 

Arkansas Ark. Code Ann. §23-79-139 Effective 1987 

Insurers, hospital and medical service corporations, and HMOs. Applies to group policies or contracts. Does not apply to: • blanket short-term 

travel accident only; 

• limited or specified 

disease; 

• conversion policies 

or contracts; and/or 

• Medicare supplement policies. 

“Alcohol or drug dependency”means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social, or occupational functioning and that may, but need not, include a pattern of tolerance and withdrawal. 

Substance abuse mandated offer requirements: Requfer and make available benefits for the necessary care another drug dependency that are not less favorable than foly, subject to the same durational limits, dollar limits, defactors. • Allows the policy or contract holder to reject the co

native level of benefits. 

Scope of coverage: Requires any benefits provided unddency coverage to be determined “necessary care and tredrug dependency treatment facility and in a hospital. • Requires policies that provides alcohol or drug depe

annual benefits for all illnesses in excess of $6,000  for each 24-month period, a minimum benefit o

care and treatment” of alcohol or drug depende

 a lifetime minimum benefit of $12,000 for “nec

of alcohol or drug dependency; and 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 9 

State law Applicability Definitions Major provisions 

 no more than one-half of the policy’s maximum 

drug dependency for a 24-month period for the ment” of alcohol or drug dependency in any 30 

Arkansas Ark. Code Ann. §23-99-501, et. seq. [as amended by H.B. 2195 (2009)] Effective 1997 Amended 2009 

Health benefit plans and health care insurers, including those providing benefits to state and public school employees. Does not apply to: • dental, vision, specified disease, accidental injury, 

long term care, disability income, or Medicare supplement plans; 

• state workers’ 

compensation plans; 

• individual health 

benefit plans (if individuals who satisfy the insurer’s underwriting standards are offered the option to purchase a plan that includes the mandated coverage); or small employer (fewer than 50 employees) health benefit plans (if the insurer offers a plan that includes 

“Mental illness” and “substance use disorders” means those illnesses and disorders that are covered by a health benefit plan listed in the International Classification of Diseases Manual (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM). • Unless specifically otherwise 

stated, “mental illness” includes substance use disorders. 

Mental health and substance abuse parity requireme

ties that provide coverage for a mental illnesses or substvide coverage for the treatment of the mental illness or sa parity basis with other medical illnesses. Scope of coverage: Prohibits any differences in the healtreatment of mental illnesses and substance abuse disordration or frequency of coverage, the dollar amount of coquirements from those of other illnesses. • Permits affected entities to: 

 negotiate separate reimbursement rates and serv

cluding, without limitation carve-out arrangeme

 manage the provision of benefits for mental illn

used for other medical conditions, including wadmission screening, prior authorization, or othlimit coverage of services for mental illnesses tmedically necessary; 

 limit coverage to covered services authorized b

the limitations are consistent with state law; 

 use separate but equal cost-sharing features for 

lopmental disorders; and 

 use a single lifetime or annual dollar limit as ap

illnesses. 

• Permits affected entities to provide coverage for a s

used for other injuries, illnesses, and conditions (e.gment, community residential treatment programs, or grams), as long as all other requirements of state law 

• Permits affected entities to provide coverage for a s

limitation physical rehabilitation or durable medical ly is not used in the diagnosis or treatment of serioufor other injuries, illnesses, and conditions, as long state law are met. 

Benefit management: Requires the health benefit plan t
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 10 

State law Applicability Definitions Major provisions 

the mandated coverage). ical necessity criteria for mental illnesses to any current 

vidual or contracting provider upon request. • On request, requires the reason for the denial of reim

be made available to a covered individual.

• Permits affected entities to utilize common utilizatio

including without limitation preadmission screeningservice, or other mechanisms designed to limit covesary services although the protocols are not used in nesses or conditions covered by the plan. 

Out-of-network services: Requires a health benefit plan medical benefits provided by out-of-network providers tmental illness services provided by out-of-network provboth medical and mental illness benefits). Exemption for cost increases: Exempts a health benefi

quirements if the plan demonstrates that the coverage mcrease in the actual costs of coverage with respect to meand mental illness benefits by an amount that exceeds 2% 1% for each subsequent plan year. • Applies the exemption for a period of 1 year. • Requires the exemption/cost determination to be ma

by a qualified and licensed actuary who is a membeAmerican Academy of Actuaries. 

• To obtain an exemption, requires affected entities to 

determination required after it has complied with thfor the first 6 months of the plan year. 

• Requires an insurer electing to claim an exemption 

Commissioner, the policyholder or contract holder, subscribers, and enrollees covered by the plan. 

• Requires the notification to the Commissioner inclu

 a description of the number of covered lives un

at the time of the notification, and if applicable, election of the increased cost exemption; and 

 for the current and previous health benefit plan 

the actual total costs of coverage for medical anmental illness benefits under the health benefit tal costs of coverage with respect to mental illnhealth benefit plan. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 11 

State law Applicability Definitions Major provisions 

 Deems the notifications to the Commissioner to 

quires the Commissioner to make available, upoannually, an anonymous itemization of notificatmary of the data received. 

Rules of construction: Provides that nothing in the requstrued to: • require equal coverage between treatments for ment

preventive care; or 

• include a Medicare or Medicaid plan or contract, or 

demonstration program for Medicare or Medicaid c

California Cal. Ins. Code §10125 Effective 1974 

Insurers issuing group disability insurance2

which covers hospital, medical, or surgical expenses. 

No definitions. Mental health mandated offer requirements: Require

coverage for expenses incurred as a result of mental or nterms and conditions agreed upon between the group pol• Requires affected entities to communicate the availa

all group policyholders and to all prospective group they are negotiating.

Scope of coverage: If the terms and conditions include cfor nervous or mental disorders, requires the coverage to general acute care hospitals, acute psychiatric hospitals, cilities. Benefit management: Permits affected entities to negottract with a professional or institutional provider for alte

California Cal. Ins. Code §10123.6 Effective 1985 

Insurers issuing group disability insurance which covers hospital, medical, or surgical expenses. 

No definitions. Substance abuse mandated offer requirements: Requ

fer coverage for the treatment of alcoholism under terms upon between the group policyholder and the insurer. • Requires affected entities to communicate the availa

all group policyholders and to all prospective group they are negotiating. 

2 In California, health insurance is known as “disability insurance.” For more information, see AHIP’s Disability Income Protection an

 Definitions chart.
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 12 

State law Applicability Definitions Major provisions 

Scope of coverage: Provides that if the group subscriber such coverage or to coverage for treatment of chemical duse, the treatment may take place in facilities licensed to 

chemical dependency services. Benefit management: Allows a policy to subject treatmseparate deductibles, co-pays, and overall cost limitation

California Cal. Ins. Code §10123.15 Effective 1989

Group policies of disability insurance which covers hospital, medical, and surgical expenses, and which offer coverage for disorders of the brain. 

“Biologically based severe mental disorders” includes: 

• schizophrenia; • schizo-effective disorder; • bipolar disorders; • delusional depressions; and • pervasive developmental disorder. 

Mental health mandated offer requirements: Requirecoverage for the treatment of biologically based severe msame manner as for other disorders. Scope of coverage: Requires coverage to be subject to ttions applied to the treatment of other disorders of the brBenefit management: Permits affected entities to reservagnoses and to review the appropriateness of specific treto ensure that coverage is provided for only those diagnowhich are medically necessary. 

California Cal Health & Safety Code §1374.72 Effective 2000 

Health care service plans (HMOs) and insurers issuing disability insurance policies. Does not apply to the Medi-Cal program. 

“Severe mental illness” includes: • schizophrenia; • schizo-affective disorder; • bipolar disorder (manic depressive illness); • major depressive disorders; • panic disorder; • obsessive-compulsive disorder; • pervasive developmental disorders or autism; and • anorexia nervosa and bulimia 

nervosa. 

A child suffering from a “serious emotional disturbances of a child” includes a child who: 

Mental health coverage requirements: Requires affectcoverage for medical/surgical treatment to provide covermedically necessary treatment of severe mental illnesses and for serious emotional disturbances of a child under ttions applied to other medical conditions. Scope of coverage: Requires the terms and conditions ofits, co-pays, and individual and family deductibles to be health coverage as for medical/surgical coverage. • Requires benefits to include outpatient services, inp

partial hospitalization services, and prescription drucoverage for prescription drugs). 

Benefit management: Allows an insurer to use case maers, utilization review, prior authorization, co-pays, or otments. • Permits coverage to be administered through a sepa
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 13 

State law Applicability Definitions Major provisions 

• has one or more mental disorders as defined in the most 

recent DSM, other than a primary substance abuse disorder or developmental disorder, that result in behavior inappropriate to the child’s age according to expected developmental norms, and 

• meets specified criteria of 

§5600.3 of the Welfare and Institutions Code (requires substantial interference activities of daily living.) 

service plan or mental health plan, without requiring 

• Permits affected entities providing benefits through 

residing in the geographic area served by a specializ

to secure mental health services in that area. 

CaliforniaCal. Family Code §1373 and Cal. Health &Safety Code §§1250 and 1250.2 Effective 2008, 1973 and 1978 Amended N/A, 2005, and 1997 

Health care service plans (HMOs) or specialized health care service plans 

“Acute psychiatric hospital”means a health facility having a duly constituted governing body with overall administrative and professional responsibility and an organized medical staff that provides 24-hour inpatient care for mentally disordered, incompetent, or other patients referred to in Division 5 (commencing with §5000) or Division 6 (commencing with §6000) of the Welfare and Institutions Code, including the following basic services: medical, nursing, rehabilitative, pharmacy, and dietary services. “Psychiatric health facility” defined to mean a health facility, licensed by the State Department of Mental Health, that provides 24-hour inpatient care for mentally disordered, incompetent, or 

Mental health coverage requirements: Permits affectecoverage of, or for payment for, professional mental heaclusion of these services. • Requires a health care service plan that offers outpa

but does not cover these services in all of its group cto prospective group contract holders as to the availage for the treatment of mental or nervous disorders

Scope of coverage: If the terms and conditions include c

vided in a general acute care hospital or an acute psychiarestrict or modify the choice of providers, requires the coprovided by a psychiatric health facility. • Prohibits a plan from prohibiting the member from 

chologist; any marriage and family therapist, or licelicensed; any licensed registered nurse who has a mtric-mental health nursing; or any advanced practice as a clinical nurse specialist who participates in expspecialty of psychiatric-mental health nursing; to pees covered under the terms of the plan, and the healtpressly authorized by law to perform these services. 

• Requires a plan contract that provides benefits that a

of confinement in a health care facility to specify wconfinement or the number of consecutive hours of 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 14 

State law Applicability Definitions Major provisions 

other persons described in Division 5 (commencing with §5000) or Division 6 (commencing with §6000) of the Welfare and Institutions Code. 

site to the commencement of benefits. 

Benefit management: Nothing shall be construed to allobtain mental health or psychological services from a heis not directly affiliated with or under contract to the heaspecialized health care service plan to which the membe

Colorado Colo. Rev. Stat. §10-16-104(5) Effective 1992 Amended 2005 

Group policies or contracts providing hospitalization or medical benefits. 

Does not define “mental illness”but states that it does not include autism. 

Mental health parity requirements: Requires affected for conditions arising from mental illness equal to the be• Prohibits affected entities from establishing deducti

differ from those for other conditions or illnesses. 

Scope of coverage: In the case of basic coverage benefidays for inpatient care or 90 days for partial hospitalizatfit period and provides a formula for calculating exchang

from inpatient days on a 2:1 basis. • In the case of major medical coverage, requires cov

any 12-month period or 20 visits per year for outpatare provided by certain licensed entities or professio

• Allows affected entities to establish co-pay or coins

mental illness which differ from co-pays or coinsura

illnesses, provided that the co-pay and coinsurance 

• Permits the Insurance Commissioner to exempt any 

with respect to which the commissioner has determimental illness benefits are inapplicable or inappropr

Benefit management: Permits affected entities to limit are rendered by a provider who is designated by and affi

Colorado Colo. Rev. Stat. §10-16-104 (5.5) Effective 1998 Amended 2007 

Group health care service policies and contracts. Does not apply to dental, vision, Medicare supplement, long term care, home health, 

“Biologically based metal illness” means: • schizophrenia; • schizo-affective disorder; • bipolar affective disorder; • major depressive disorder; • specific obsessivecompulsive disorder; and 

Mental health parity requirements: Requires affected age for the treatment of biologically based mental illness than the coverage provided for any other physical illnessauthorization or utilization review mechanisms. • Requires all affected entities to provide coverage fo

disorders that is no less extensive than the coverage ness. 

• Permits different mechanisms for pre-authorization 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 15 

State law Applicability Definitions Major provisions 

community based care, disability income, and specified disease policies or contracts. 

• panic disorder. “Mental disorder” means • posttraumatic stress disorder; • drug and alcohol disorders; • dysthymia; • cyclothymia; • social phobia; • agoraphobia with panic disorder; and • general anxiety disorder. The term includes anorexia nervosa and bulimia nervosa to the extent those diagnoses are treated on an out-patient, day treatment and in-patient basis, exclusive of residential treatment. 

tween medical specialties to the extent they are not spect to a covered person or a mental health providecal illness. 

Scope of coverage: Provides that the benefits need not bthat such benefits duplicate benefits provided under Colowhich requires parity of coverage for autism if autism is 

Benefit management: Permits affected entities to use u

isms in determining whether to provide coverage for druand eating disorders even if the carrier does not use utiliin determining whether to provide coverage for a physic• Permits affected entities to limit coverage to service

provider who is designated by and affiliated with th

Colorado Colo. Rev. Stat. §10-16-104 (9) Effective 1995 

Insurers. No definitions. Substance abuse mandated offer requirements: Requ

age for the treatment of conditions arising from alcoholiScope of coverage: Requires coverage to include 45 dayannually and outpatient benefits of $500 annually. • Permits insurers to establish co-pays for substance a

from other conditions or illnesses; however, prohibitablishing at co-pay that exceeds 50% for substance 

• Permits insurers to establish deductibles for such be

for any other condition or illness. 

• Prohibits benefits from being payable unless the pat

continuum of care, including detoxification and reh

Connecticut Conn. Gen. Stat. §38a-514 Effective 2000 

Individual and group health insurance policies. 

“Mental and nervous conditions”

mean mental disorders, as defined in the most recent edition of the DSM. • The term appears to include 

Mental health coverage requirements: Requires health fits for the diagnosis and treatment of mental or nervous • Prohibits such policies from establishing any terms, 

place a greater financial burden on an insured for acment of a mental or nervous condition than for the d
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 16 

State law Applicability Definitions Major provisions 

alcoholism and drug addiction. 

• The term does not include 

mental retardation, learning disorders, motor skills disorders, communication disorders, caffeine-related disorder, relational problems, and additional conditions that may be a focus of clinical attention that are not otherwise defined as mental disorders in the most recent DSM. 

medical/surgical condition. 

Scope of coverage: Permits benefits to be provided by lchologists, social workers, and marital and family therap• Requires, in the case of benefits based upon confine

ment facility, benefits to be payable only in situatio

 the insured has a serious mental illness which s

person’s thought, perception of reality, emotiongrossly impairs behavior as manifested by recen

 the insured has been confided in a hospital for s

at least three days immediately preceding such tial treatment facility; and 

 such illness would otherwise necessitate contin

pital if such care and treatment were not availabtreatment center for children and adolescents. 

• Requires services rendered for confinement in a resi

be based on an individual treatment plan. 

Rule of construction: Permits affected entities to excludefits are included in a separate policy issued to the same 

Connecticut Conn. Gen. Stat. §38a-553 Effective 2001 

Individual and group heath care plans. 

“Mental conditions” is defined under §38a-514 (see above.)

Mental health coverage requirements: Requires affectimum standard benefits including the diagnosis or treatmaccordance with requirements established under §38a-51Scope of coverage: Prohibits the application of deductibtreatment of mental and nervous conditions that exceeds $1,000 per covered individual, or $2,000 per covered famadjusted annually consistent with the CPI. • Permits covered expenses incurred after the applicab

reached to be paid at a rate of 50%. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 17 

State law Applicability Definitions Major provisions 

Delaware Del. Code Ann. §18.35.3577 Effective 1999 

Carriers that provide health insurance and health benefit plans. Does not apply to accident-only, credit, dental, vision, Medicaid, long-term care, disability income, specified disease, hospital confinement indemnity, or limited health benefit coverages. 

“Serious mental illness” means any of the following biologically based mental illnesses as defined in the most recent edition of the DSM: 

• schizophrenia; • bipolar disorder; • obsessive-compulsive disorder; • major depressive disorder; • panic disorder; • anorexia and bulimia nervosa; • schizo-affective disorder; or • delusional disorder. 

The term does not include alcoholism or other drug dependencies. 

Mental health parity requirements: Requires affected 

age of serious mental illness that place no greater financ

covered services than for the diagnosis and treatment of covered by the health benefit plan. Scope of coverage: Permits affected entities to limit cov

 rendered by a licensed mental health profession found to be medically necessary; and  received in compliance with the policy’s admin

• Permits affected entities to further condition covera

mental illness in the same manner and to the same eother illnesses and diseases or conditions, including ral requirements. 

Benefit management: Permits a carrier to, directly or b

qualified entity, manage the mental health benefit in ordvices provided in the diagnosis and treatment of a seriouservices that are deemed medically necessary. • Permits the management of benefits for serious men

used for the management of benefits provided for otby management methods unique to mental health be

 Such methods may include, pre-admission scree

utilization review, and the development and mo

 Permits affected entities to further condition co

rious mental illness in the same manner and to for all other illnesses and diseases or conditionsand referral requirements. 

• Provides that the ability to manage benefit shall not 

carrier to employ the same benefit management proillnesses that are employed for the management of ocovered by the health benefit plan or to require paritrate, or dollar value, of claims denied. 

Out-of-network services: Permits a health benefit plan to exclude the required coverage for out-of-network serv

Florida Group insurers, HMOs, “Mental and nervous disorders” Mental health mandated offer requirements: Require
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 18 

State law Applicability Definitions Major provisions 

Fla. Stat. ch. §37.627.668 Effective 1992 

and nonprofit hospital and medical service plan corporations. 

means those mental and nervous disorders as defined in the standard nomenclature of the American Psychiatric Association. 

benefits for the necessary care and treatment of mental aScope of coverage: Requires such benefits to include inpartial hospitalization benefits, and outpatient benefits cits, dollar amounts, deductibles, and coinsurance factors than for physical illnesses generally, except that: 

 inpatient benefits may not be less than 30 days 

 outpatient benefits may not be less than $1,000 

 partial hospitalization must be provided under d

cian. 

• Permits affected entities to apply different durationa

and coinsurance factors for physical illnesses if benand outpatient limitations. 

Florida Fla. Stat. ch. §37.627.669 Effective 1993

Group insurers, HMOs, and nonprofit health care service plans. 

"Substance abuse impaired"means a condition involving the use of alcoholic beverages or any psychoactive or mood-altering substance in such a manner as to induce mental, emotional, or physical problems and cause socially dysfunctional behavior. 

Substance abuse mandated offer requirements: Requfer coverage for the necessary care and treatment of subssons. Scope of coverage: Requires inpatient or outpatient bentreatment programs for the treatment of substance abuse • Requires:

 benefits to be available to covered individuals o

 a minimum lifetime benefit of $2,000; 

 a maximum of 44 outpatient visits (does not inc

 a maximum benefit payable for an outpatient vi

Benefit management: Requires benefits to be payable ocensed physician or psychologist and if services are provdited by the Joint Commission on Accreditation of Healt
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Georgia Ga. Code Ann. §33-24-28.3 Effective 1998 

Insurers, nonprofit medical and hospital service plans, health care plans, fraternal benefit societies, and HMOs. 

No definitions. Substance abuse coverage requirements: Does not ma

stance abuse. Scope of coverage: Prohibits affected entities that provi

ment of alcoholism or drug addiction, from denying paypital specializes in the treatment of alcoholics or drug admarily for the treatment of such persons. 

Georgia Ga. Code Ann. §33-24-28.1 Effective 1981 Amended 1998 

Individual accident and sickness insurance benefit plan, policy, or contract. 

"Mental disorder" means all disorders in the DSM or ICD classification. Mental health mandated offer requirements: Require

available, either as a part of or as an optional endorsemeviding major medical insurance coverage, coverage for torders. Scope of coverage: Requires such optional overage to bprovide at least the same degree of coverage as that provplan, policy, or contract for the treatment of other types • Requires such optional coverage to cover at least 30 

and 48 outpatient visits annually. 

• Prohibits the optional endorsement from containing 

or other limitations as to coverage, deductibles, or cwhich apply to the treatment of mental disorders ungenerally to other similar benefits provided or paid policy, or contract. 

Georgia Ga. Code Ann. §33-24-29 Effective 1998 

Group or blanket accident and sickness insurance plans or contracts providing major medical benefits. Does not apply to policies issued to an employer in another state which provide coverage for employees in another state who are em-

“Mental disorder” means the same as defined in the DSM or ICD.

Mental health mandated offer requirements: Requireavailable, either as a part of or as an optional endorsemeviding major medical insurance coverage, coverage for torders. Mental health coverage requirements: Prohibits affeccoverage for the treatment of mental disorders with annuits that are more extensive than those for physical illnessScope of coverage: Prohibits affected entities from inclureductions, or other limitations than physical illnesses, eon inpatient treatment days and outpatient treatment visi
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 20 

State law Applicability Definitions Major provisions 

ployed by such employer, providing major medical benefits covering small groups. 

• Permits differences in deductibles or coinsurance to 

exceed the deductible for physical illnesses. 

• Limits out-of-pocket costs for individuals to $2,000 

justments thereafter according to the CPI for health 

Hawaii Haw. Rev. Stat. §431M, et. seq. Effective 1988 Amended 2007 

All individual and group accident and health or sickness insurance policies, individual or group hospital or medical service plan contracts, nonprofit mutual benefit societies, and HMO contracts. Does not apply to specified disease policies or other specialized coverage. 

“Alcohol dependence” means any use of alcohol which produces a pattern of pathological use causing impairment in social or occupational functioning or produces physiological dependency evidenced by physical tolerance or withdrawal. “Drug dependence” means any pattern of pathological use of drugs causing impairment in social or occupational functioning and producing psychological or physiological dependency or both, evidenced by physical tolerance or withdrawal. “Mental illness” means a syndrome of clinically significant psychological, biological, or behavioral abnormalities those results in personal distress or suffering, impairment of capacity for functioning, or both as defined in the DSM or ICD. • Provides that epilepsy, senility, mental retardation, or other developmental disabilities 

and addiction to or abuse of intoxicating substances do not in and of themselves constitute a mental disorder. 

Mental health and substance abuse coverage requirementities to cover services for the treatment of mental illndependency. Scope of mental health and substance abuse coveragepital services from being less than 30 days per year. • Prohibits visits to physicians, psychologists, license

marriage and family therapists, or advanced practice mental health specialty or subspecialty of less than 3pital, non-hospital facility, or to a mental health out

• Permits a 2:1 day exchange ratio of non-hospital res

hospitalization, or day treatment services with in-ho

• Prohibits the total covered benefit for outpatient ser

per year (two of the 24 visits shall apply only to me

• Limits covered benefits for alcohol and mental illne

provided by a physician, psychologist, licensed clinriage and family therapist, or advanced practice RN ically necessary at the least restrictive appropriate le

• Requires covered benefits for mental illnesses to be 

dures (including prior, concurrent, and retrospective payment or reimbursement. 

• Requires services to be provided as part of an indivi

that is reasonably expected to improve the patient’s 

Scope of substance abuse coverage: Requires detoxificvided in a hospital or in a non-hospital facility which haagreement with a hospital for emergency, medical, and m

vices. • Requires coverage of: 

 room and board;  diagnostic x-rays;  laboratory testing and drugs;  equipment use; 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 21 

State law Applicability Definitions Major provisions 

“Serious mental illness” means schizophrenia, schizo-affective disorder, and bipolar disorder as defined in the most recent version of the DSM, which is of sufficient severity to result in substantial interference with the activities of daily living. 

 special therapies; and  supplies. 

• Requires alcohol or drug dependence treatment cov

non-hospital residential, or day treatment substance vided in a hospital or non-hospital facility to the extgist, licensed clinical social worker, marriage and fapractice RN determines that the person suffers from dence, or both.  Excludes judicially referred detoxification serv

grams. 

 Requires at least 2 treatment episodes per lifetim

• Requires detoxification services to be part of the co

but not in the treatment episode limitation of the mequirements. 

Idaho Idaho Code §67-5761A Effective 2006

State employees group health coverage. 

"Serious mental illness" means any of the following psychiatric illnesses as defined by the American psychiatric association in the(DSM-IV): • schizophrenia; • paranoia and other psychotic 

disorders; 

• bipolar disorders (mixed, 

manic, and depressive); 

• major depressive disorders 

(single episode or recurrent); 

• schizoaffective disorders (bipolar or depressive); • panic disorders; and • obsessive-compulsive disorders. "Serious emotional disturbance"means an emotional or behavioral disorder, or a neuropsychiatric condition, which: results in a serious disability; requires sustained 

Mental health coverage requirements: To be considerequitable, requires state employees group health care serbenefits and cover services that are essential to the effecmental illnesses and serious emotional disturbances in a • is not more restrictive or more generous than benefi

for other major illnesses; 

• provides clinical care, but does not require partial ca

ness or serious emotional disturbance; and 

• is consistent with effective and common methods of 

costs for other major illnesses. 

Cost report: Requires the Department of Administration Legislature and to the Legislative Health Care Task Forcany additional costs incurred in providing the required cyear period.
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

treatment interventions; and causes the child's functioning to be impaired in thought, perception, affect, or behavior. • A disorder is considered to 

"result in a serious disability" if it causes substantial impairment of functioning in family, school, or community. While a substance abuse disorder may coexist with a serious emotional disturbance, it does not, by itself, constitute a serious emotional disturbance. 

Illinois 215 Ill. Comp. Stat. 5/370c Effective 1991 Amended 2008 

Mental health coverage offering requirements apply to every insurer delivering, issuing for delivery, or renewing or modifying group accident and health policies providing coverage for hospital or medical treatment or services for illnesses on an expense-incurred basis. Mental health coverage requirements apply to insurers amending, delivering, issuing, or renewing group accident and health policies providing for hospital or medical expenses.

“Serious mental illness” means the following disorders as defined in the most current edition of the DSM: • schizophrenia; • paranoid and other psychotic 

disorders; 

• bipolar disorders (hypomanic, manic, depressive, and 

mixed); 

• major depressive disorders 

(single episode or recurrent); 

• schizoaffective disorders (bipolar or depressive); • pervasive developmental disorders; • obsessive-compulsive disorders: • depression in childhood and 

adolescence; 

• panic disorders; • post-traumatic stress disordMental health coverage requirements: Requires affect

erage for treatment of serious mental illness under the sacoverage for hospital or medical expenses related to othe• Requires coverage for serious mental illnesses to be 

rational and amount limits, deductibles, and co-insuprovided for other covered illnesses and diseases. • Requires affected entities to offer to the applicant or 

age for reasonable and necessary treatment and servor nervous disorder or conditions, other than serious limits provided in the policy for other disorders or c

 Permits a requirement for the insured to pay up 

curred as a result of treatment or services, and the lesser of $10,000 or 25% of the lifetime po

 Permits insureds to select a physician licensed 

its branches, licensed clinical psychologist, licer, or licensed clinical professional counselor oered mental, emotional, or nervous disorders o

Scope of coverage: For medically necessary treatment o

coverage of 45 days of inpatient and 60 outpatient visits vidual outpatient visits). • Prohibits the imposition of a lifetime limit on the nu
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 23 

State law Applicability Definitions Major provisions 

Mental health coverage requirements do not apply to coverage provided by employers who have 50 or fewer employees. 

ers (acute, chronic, or with delayed onset); and 

• anorexia nervosa and bulimia 

nervosa. 

Does not require coverage for treatment of an addiction to or a mental illness resulting from an illegal use of a controlled substance or cannabis. 

treatment or the number of outpatient visits. 

• Requires the same amount limits, deductibles, co-pa

for serious mental illness as are imposed for physica

• Requires outpatient visits to be covered under the sa

applicable for outpatient visits for the treatment of p

Benefit management: Permits coverage to be provided 

plan. • Permits the reimbursing insurer to request, and requ

of serious mental illness to furnish, medical records substantiate that initial or continued treatment is at a

sary. 

• Requires a review process for medical necessity dis

insurer the patient’s provider. Upon determination ly necessary, requires the insurer to provide reimbur

• Requires insurers to make medical necessity determ

of serious mental illness in a manner consistent with ered diseases or illnesses. 

Illinois 215 Ill. Comp. Stat. 5/367 Effective 1995 

Group accident and health insurance policies. 

No definitions. Substance abuse coverage requirements: Requires aff

inpatient hospital coverage for sickness to include covercoholism. 

Indiana Ind. Code §§27-8-5-15.5 and 27-13-7-14.8 Effective 1992 Amended 1993 

Group and individual policies offered by accident and sickness insurers. 

“Alcohol abuse” means repeated episodes of intoxication or drinking which impair health or interfere with an individual's effectiveness on the job, at home, in the community, or operating a motor vehicle. “Drug abuse” means the following if harmful to the individual or society: 1. psychological or physical deMental health and substance abuse coverage requirem

entities providing coverage for inpatient services for the substance abuse, or both from excluding coverage for intreatment of mental illness or substance abuse that are prmental health center or by any psychiatric hospital licenof health or the division of mental health and addiction t
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 24 

State law Applicability Definitions Major provisions 

pendence on the effect of drugs or harmful substances; or 

2. abuse of the use of drugs or 

harmful substances. 

"Mental illness" means a psychiatric disorder that: • substantially disturbs an individual's thinking, feeling, 

or behavior; and 

• impairs the individual's ability to function. The term includes mental retardation, alcoholism, and addiction to narcotics or dangerous drugs. “Substance abuse” means drug or alcohol abuse. 

Indiana Ind. Code §§27-8-5-15.6 and 27-13-

7-14.8 Effective 1992 Amended 1995 

Group and individual policies offered by accident and sickness insurers, HMOs, and state employee health benefit plans. Does not apply to accident-only, credit, dental, vision, Med Supp, long-term care, disability income, workers comp, supplemental liability, auto medical, specified disease, shortterm insurance, limited benefit plans issued as individual policies, and 

“Coverage of services for a mental illness” means those services defined under the policy. • The term does not include 

services for the treatment of substance abuse or chemical dependency. 

Mental health and substance abuse parity requireme

affected entities to offer mental health benefits. • For individual policies and group policies issued to 

50 employees that provide coverage for mental illneof treatment limits or financial requirements for servless such limits or requirements are also imposed on surgical conditions. 

• For individual and group policies issued to employe

ployees that provide coverage for treatment of substdependency, prohibits the imposition of treatment liments for those services unless such limits and requcoverage for medical or surgical conditions. 

Benefit management: Permits benefits to be delivered utem. Exemption for cost increases: Permits a policy to not cty requirements if the coverage causes a premium increa
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 25 

State law Applicability Definitions Major provisions 

policies stipulating daily, weekly, or monthly payments to an insured during hospital confinement. 

Iowa Iowa Code §514C.22 Effective 2005 Iowa Administrative Code §191 - 35.3(509)(3) Effective 2006

Public employee programs and carriers issuing group policies, contracts, or plans providing for third-party payment or prepayment of health, medical, and surgical coverage benefits, or an organized delivery system. Applies to such policies, contracts, or plans issued to employers with 50 or more fulltime employees providing coverage for the treatment of mental illness. Does not apply to: accident only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner; dis-

"Biologically based mental illness" means the following psychiatric illnesses as defined under the most current edition of the DSM: • schizophrenia, including all 

specific subtypes of schizophrenia; 

• bipolar disorders, including 

all specific types of bipolar disorders; 

• major depressive disorders, 

including all specific subtypes of major depressive disorders; 

• schizo-affective disorders; • obsessive-compulsive disorders; • pervasive developmental disorders; and • autistic disorders.

Mental health coverage requirements: Requires affecterage for biologically based mental illnesses. Scope of coverage: Prohibits affected entities from imp

or lifetime limit on biologically based mental illness covpolicy, contract, or plan imposes such limits on substantand surgical coverage benefits. • Requires affected entities to impose the same deduc

payments for health, medical, surgical, and mental h

• Requires affected entities to, at a minimum, allow fo

outpatient visits annually. 

• Permits affected entities to exclude from coverage b

viding:  marital, family, educational, developmental, or  custodial care;  services and supplies that are not medically nec

priate; and 

 experimental treatments. 

Benefit management: Permits affected entities to mana

through “common methods” including, but not limited to• capitated payment systems; • prospective reimbursement rate systems; • utilization control systems; • incentive systems for the use of least restrictive and • PPOs; or • any other system, method, or organization designed 

ically necessary and clinically appropriate. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 26 

State law Applicability Definitions Major provisions 

ability income insurance coverage, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, or automobile medical payment insurance; or individual accident and sickness policies issued to individuals or to individual members of a member association. 

Kansas Kan. Stat. Ann. §40-2,105 [as amended by H.B. 2214 (2009)] Effective 1998 Amended 2009 

Insurers or HMOs offering individual or small employer (defined as 2-50 employees) accident and sickness policies. Does not apply to Medicare supplement policies. 

“Mental illness, alcoholism, drug abuse or substance use” meansdisorders specified in the DSMIV. “Treatment limitations” includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. 

Mental health coverage requirements: Requires affectreimbursement for alcoholism, drug abuse, or other subsspecified below. Scope of coverage: Requires affected entities to provide• not less than 45 inpatient days annually for in-patien

ness in a licensed facility;, 

• not less than 30 days annually when a person is con

alcoholism, drug abuse or substance abuse disorders facility, a treatment facility for alcoholics or drug abhealth centers or clinics, or a psychiatric hospital; an

• the same deductibles, co-pays, coinsurance, out-of-p

ment limitations as apply to other covered services, $15,000 lifetime limit, with no annual limits when inecessary for the treatment or by a licensed Kansas 

Benefit Management: Allows affected entities to performental illness, so long as it is conducted in accordance wview laws. 

Kansas Kan. Stat. Ann. 

Any group health insurance policy, medical or “Mental illness, alcoholism, drug abuse or substance use” means Mental health and substance abuse coverage requirem

entities to include coverage for the diagnosis and treatm
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 27 

State law Applicability Definitions Major provisions 

§40-2, 105a [as amended by H.B. 2214 (2009)] Effective 1998 Amended 2009 

hospital service plan contract, fraternal benefit society or HMO providing medical, surgical or hospital expense coverage. • Also applies to the 

state employee health care benefits program and municipal funded pools. 

Does not apply to small employers (defined as 2-50 employees). • Also does not apply to specified 

disease, specified accident or accident only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance, vision care, Medicare supplement, or any other limited supplemental benefit policy. 

any disorder as such terms are defined in the DSM-IV. “Treatment limitations” includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. 

alcoholism, drug abuse, or other substance use disorders• Requires coverage to be subject to the same deducti

out-of-pocket expenses, treatment limitations, and ocovered services. 

Scope of coverage: Requires reimbursement to be provicensed adult care home, drug abuse treatment facilities, 

centers or clinics, psychiatric hospitals, or by a licensed • Requires coverage to include treatment for inpatient 

mental illness, alcoholism, and drug abuse or substa

Benefit Management: Allows affected entities to performental illness, so long as it is conducted in accordance wview laws. 

Kansas Kan. Stat. Ann. §40-2258 [as amended by H.B. 2214 (2009)] 

Insurers offering coverage through a group policy or certificate providing hospital, medical or surgical expense benefits. 

“Mental illness benefits” means 

benefits with respect to mental health services, as defined under the terms of the policy. “Alcoholism, drug abuse or subMental health and substance abuse parity requireme

affected entities to offer mental illness or alcoholism, druse disorders benefits. Scope of coverage: Prohibits affected entities that do no

time or annual limit on substantially all hospital, medica
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 28 

State law Applicability Definitions Major provisions 

Effective 2009

Does not apply to group accident and health insurance policies sold to a small employer (defined as 2 – 50 employees). 

stance use disorder benefits”means benefits with respect to services for the treatment of alcoholism, drug abuse or other substance use disorders, as defined under the terms of the policy. “Mental illness, alcoholism, drug abuse or substance use” means disorders as specified in the DSM-IV. 

benefits from imposing an aggregate lifetime or annual lalcoholism, drug abuse or other substance use disorders • Requires affected entities that include an aggregate 

substantially all hospital, medical and surgical expeplan to either: 

 apply the applicable limit both to the hospital, m

pense benefits and the mental illness, alcoholis

substance use disorder benefits and not distingusuch limit between the types of benefits; or 

 not include any limit on mental illness, alcoholi

substance use disorder benefits that is less than hospital, medical, and surgical expense benefits

 Allows the Commissioner to adopt rules to addr

group policy does not apply a lifetime or annuaent lifetime or annual benefits to different categand surgical expense benefits that substitutes an plicable lifetime or annual limits that takes in to erage of the lifetime or annual limits applicable 

Benefit management: Provides that the law is not to be terms and conditions of a policy which does include mendrug abuse or other substance use disorders benefits, incing: cost sharing; limits on the number of visits or days orelating to medical necessity; and requirements relating scope of mental illness or alcoholism, drug abuse or othebenefits. Exemption for cost increases: Provides that the requirecoverage mandate will result in an increase in the cost unpercent in the first plan year and 1 percent in each subse• Requires determinations as to increases in actual co

in writing and certified by a qualified and licensed agood standing of the American Academy of Actuari

Kentucky Ky. Rev. Stat. Ann. §§304.18-130, 304.18-140, 

Insurers providing major medical or outpatient care benefits contracts. "Alcohol and other drug abuse" means a dysfunctional use of al- cohol or other drugs or both, cha- racterized by one or more of the Substance abuse mandated offer requirements: Requ

fer the master policyholder the option to purchase in new benefits for treatment of alcoholism. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 29 

State law Applicability Definitions Major provisions 

304.18-160; and 222.005 Effective 1980 

Does not apply to disability and accident income benefits and basic health care contracts that do not provide major medical or outpatient care. 

following patterns of use: • the continued use despite 

knowledge of having a persistent or recurrent social, legal, occupational, psychological, or physical problem that is caused or exacerbated by use of alcohol or other drugs or both; 

• use in situations which are 

potentially physically hazardous; 

• loss of control over the use of 

alcohol or other drugs or both; and 

• use of alcohol or other drugs 

or both is accompanied by symptoms of physiological dependence, including pronounced withdrawal syndrome and tolerance of body tissues to alcohol or other drugs or both. 

"Treatment for alcoholism"means services and programs for the care and rehabilitation of intoxicated persons and persons suffering from alcohol and other drug abuse, including: • detoxification services on a 

twenty-four (24) hour basis in or near population centers which meet the immediate medical and physical needs of persons intoxicated from the use of alcohol or drugs, or both, including necessary diagnostic and referral services. 

Scope of coverage: Requires coverage for treatment to b

 emergency detoxification treatment (three days

 residential treatment (10 days, $50 a day); and 

 outpatient treatment (10 visits, $10 a visit). 

• Conditions coverage on completion of a program of 

ance of a Kentucky physician or a professional desiwho is a staff member of a treatment facility accredsion on Accreditation of Hospitals. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 30 

State law Applicability Definitions Major provisions 

The services shall be provided in either a hospital or a licensed alcohol and other drug abuse program; 

• rehabilitation services offered 

on an inpatient or outpatient basis for the purposes of treating an individual's alcohol and other drug abuse problem in a licensed alcohol and other drug abuse program; and 

• involuntary treatment ordered 

for a person suffering from alcohol and other drug abuse. 

Kentucky Ky. Rev. Stat. Ann. §304.18-036 Effective 1987 

Group policies or contracts of general health insurance. 

“Mental illness” means psychosis, neurosis or an emotional disorder. Mental health mandated offer requirements: Require

clude an offer of coverage for the inpatient and outpatienness, at least to the same extent and degree as coverage pof physical illness. 

Kentucky Ky. Rev. Stat. Ann. §§304.17A-660, 304.17A- 661, and 304.17A-665 Effective 2000 Amended 2002 

Health benefit plans which includes any: hospital or medical expense policy or certificate; nonprofit hospital, medical-surgical, and health service corporation contract or certificate; provider sponsored integrated health delivery network; a self-insured plan or a plan provided by a MEWA, to the extent permitted by ERISA; 

“Mental health condition” means any condition or disorder that involves mental illness or alcohol and other drug abuse as defined in statute and that falls under any of the diagnostic categories listed in the DSM-IV or ICD. 

Mental health parity requirements: Requires health berage for treatment of mental health conditions to providment for a mental health condition under the same terms vided for treatment of a physical health condition. Scope of coverage: Requires treatment of a mental healnot limited to: outpatient, inpatient, residential, partial hment, emergency detoxification, or crisis stabilization se• Requires expenses for mental health and physical co

for purposes of meeting deductible and out-of-pockhealth benefit plan. 

• Permits a health benefit plan that does not otherwise 

of care under the plan or does not provide for the saof care for all health or mental conditions to provide mental health conditions through a managed care or
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

and HMO contract. Does not apply to group health benefit plans covering fewer than 51 employees, or to individual health benefit plans. Does not apply to standard health benefit plans excluding coverage for mental health conditions that had excluded such conditions on January 1, 2000. Does not apply to: policies covering only accident, credit, dental, or disability income; fixed indemnity medical expense reimbursement policies; long-term care, Medicare supplement, specified disease, or vision care policies; short-term coverage; student insurance; medical expense reimbursement policies specifically designed to fill gaps in primary coverage, coinsurance, or deductibles and provided under a separate policy, certificate, or contract; or limited health service benefit plans. 

Cost report: Requires the Commissioner, 60 days prior regular sessions of the Generally Assembly, to submit a Research Commission on the cost impact of the mental h

ments. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 32 

State law Applicability Definitions Major provisions 

Louisiana La. Rev. Stat. Ann. §22:669 Effective 2000 

Hospital, health, or medical expense insurance policies, hospital or medical service contracts, employee welfare benefit plans, contracts or other agreements with a HMO or PPO, health and accident insurance policy, or other insurance contract of this type, including group insurance plans, self-insurance plans, and the state employee’s group benefits program. Does not apply to individually underwritten health insurance plans, short term limited duration health insurance policies, and individually underwritten limited benefit and supplemental health insurance policies. 

“Severe mental illness” means: • schizophrenia or schizoaffective disorder; • bipolar disorder; • pervasive developmental disorder or autism; • panic disorder; • obsessive-compulsive disorder; • major depressive disorder; • anorexia/bulimia; • Asperger’s disorder; • intermittent explosive disorder; • posttraumatic stress disorder; • psychosis not otherwise specified (NOS) when diagnosed 

in a child under 17; 

• Rett’s disorder; and • Tourette’s disorder. 

Mental health coverage requirements: Requires affectfits payable for the treatment of severe mental illness unand conditions as benefits are paid under policies for all or accidents. • Requires affected entities to also offer an optional p

of mental disorders other than severe mental illness tances and conditions as benefits paid for all other dcidents. 

Scope of coverage: Requires a minimum of 45 inpatient ual, per calendar year. 

 Allows the exchange of two days of partial hos

treatment for each day of inpatient treatment. 

• Requires 52 outpatient visits per covered individual 

ing an intensive outpatient program. 

• Allows the exchange of 1 inpatient day of treatm

• Requires benefits to be payable when the treatment 

Louisiana licensed physician or psychologist, or whin connection with diagnostic consultation provided dered by a licensed clinical social worker who is a mcal social work registry. 

• Prohibits provisions for a waiting period in excess o

effective date before benefits are payable for the treillness or other mental disorders. 

Benefit management: Allows the management of mentsuch methods as pre-admission screening prior to authorother mechanism designed to limit coverage for services to those deemed medically necessary by a licensed ment

Louisiana La. Rev. Stat. Ann. §22:215.5 Effective 1982 

Group, blanket, and franchise health insurance. 

No definitions. Substance abuse mandated offer requirements: Requ

clude an option for benefits for the treatment of alcoholidered or prescribed. Scope of coverage: If coverage is provided, requires covscribed by a Louisiana licensed physician and received i
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

or private facility, or portion thereof, licensed and authostate authority to provide such treatment. 

Maine Me. Rev. Stat. Ann. Tit. 24A, §2842 Effective 1984 

Insurers issuing group health care contracts providing hospital care. Does not apply to employee group insurance policies with 20 or fewer employees. 

No definitions. Substance abuse coverage requirements: Requires aff

benefits as required to any subscriber or other person cofor the treatment of alcoholism and other drug dependenplan. • Requires affected entities to provide written notifica

uals of these alcoholism and drug dependency benef

Scope of coverage: Requires minimum benefits to incluplan) state licensed residential treatment at a hospital or treatment center and outpatient care provided by state lic

• Permits policies to contain provisions for maximum 

and reasonable limits, deductibles, and exclusions to visions are not inconsistent with the requirements. 

Reports to Superintendent: Requires affected entities t

Superintendent of Insurance their experience with providing claims information. 

Maine Me. Rev. Stat. Ann. Tit. 24A, §2843 Effective 1996 

Insurers issuing group health care contracts. Does not apply to employee group insurance policies with 20 or fewer employees. Does not apply to accidental injury, specified disease, hospital indemnity, Medicare supplement, long-term care, or other limited benefit health insurance policies. 

“Person suffering from mental illness” means a person whose psychobiological process are impaired severely enough to manifest problems in the areas of social, psychological or biological functioning. Also requires such person to: • have a disorder of thought, 

mood, perception, orientation or memory which impairs judgment, behavior, capacity to recognize or ability to cope with the ordinary demands of life; and 

• manifest an impaired capaciMental health coverage requirements: Requires affect

fits for treatment for mental illness. • Requires contracts to provide for the treatment and 

nesses under terms and conditions that are no less exvided for treatment for physical illnesses. Scope of coverage: Requires affected entities to provide 

health care to a person suffering from mental illness, incinpatient care, outpatient care, day treatment services, anes. • Requires mental illness to be diagnosed by a license

physician or a licensed psychologist who has receivgy specializing in the evaluation and treatment of m

• Prohibits separate maximums, deductibles, coinsura

limits for physical and mental illness, and separate obenefit period of not more than 12 months for physi
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 34 

State law Applicability Definitions Major provisions 

ty to maintain acceptable levels of functioning in the areas of intellect, emotion or physical well-being. 

“Mental illness” means any of the following categories of mental illness as defined in the DSM, except for those that are designated “V” codes: • psychotic disorders, including schizophrenia; • dissociative disorders; • mood disorders; • anxiety disorders; • personality disorders; • paraphilias; • attention deficit and disruptive behavior disorders; • pervasive developmental disorders; • tic disorders; • eating disorders, including 

bulimia and anorexia; and 

• substance abuse-related disorders. 

• Prohibits limitations on coverage or benefits for me

limitation is also imposed for physical illness. 

• Requires co-pays for mental illness to be actuarially 

illness coinsurance requirements or, if there are no cprohibits co-pays from exceeding co-pays or coinsu

• Requires medication management visits associated w

covered in the same manner as such visit for the treaand prohibits such visits from being calculated in anit limit. 

• Permits policies to contain provisions for maximum 

and reasonable limits, deductibles, and exclusions to visions are not inconsistent with the requirements. 

Benefit management: Requires a provider, when makinterminations, to use the same criteria for treatment for mment for physical illness under the group contract. • Permits mental health benefits and coverage to be p

naged care system if benefits and coverage provided illness are provided on an expense-incurred basis. 

Reports to Superintendent: Requires affected entities tSuperintendent of Insurance their experience with providing claims information. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Maine Me. Rev. Stat. Ann. Tit. 24A, §§2835 and 2744Effective 2004 Amended 2006 

Insurers offering group and individual health policies. 

“Professionals” means: • psychologists licensed to 

practice in ME; 

• certified social workers licensed for the independent 

practice of social work in ME; 

• licensed clinical professional 

counselors licensed for the independent practice of counseling in ME; 

• licensed nurses certified by 

the American Nurses' Association as clinical specialists in adult psychiatric and mental health nursing or as a clinical specialists in child and adolescent psychiatric and mental health nursing; 

• marriage and family therapists licensed as a marriage 

and family therapists in ME; and 

• licensed pastoral counselors 

licensed as pastoral counselors in ME. 

Mental health coverage requirements: Requires a polifor services within the lawful scope of practice of a healreimbursement for these services if the services are perfoprofessional. • Requires affected entities providing coverage for m

to offer coverage for those services when performprofessional licensed in ME. 

Maryland Md. Code Ann. Ins. §15-802 Effective 1994 Amended 2005 

Individual and group health insurance policies. 

No definitions. Mental health parity requirements: Requires affected 

for the diagnosis and treatment of mental illness, emotiodisorder, and alcohol abuse disorder under the same termply under the policy or contract for the diagnosis and trenesses. Scope of coverage: Requires the following minimum be

 a number of days for inpatient benefits at a lice

hospital inpatient benefits, and terms and condibenefits at least equal to those that apply to the 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

the policy or contract for physical illnesses; 

 60 days of partial hospitalization under the sam

apply for physical illnesses; and 

 outpatient coverage, including psychological an

ing for diagnostic purposes, at a rate, after the dthan: 80% for the first five visits annually; 65% 50% for the 31st and any subsequent visit annua

• Prohibits separate lifetime limits, deductibles, coins

limits for physical and mental illnesses. 

• Requires co-pays to be actuarially equivalent to any 

quirements or if there are no coinsurance requirememental illness, emotional disorders, or drug and alcogreater than those required for physical illness. 

Benefit management: Limits benefits to medically nececonditions • Permits benefits to be delivered under a managed ca

Maryland Md. Code Ann. Ins.§19-703.1 Effective 2005 

HMOs No definitions. Mental health parity requirements: Requires affected 

for the diagnosis and treatment of mental illnesses, emotdisorders, and alcohol abuse disorders under the same teapply under the policy or contract for the diagnosis and nesses. Scope of coverage: Requires the following minimum be• inpatient benefits in a licensed or certified facility (i

benefits); 

• 60 days of partial hospitalization; and • outpatient coverage, including psychological and ne

for diagnostic purposes, at a rate, after the applicablthan 80% for the first 5 visits annually, 65% for visifor the 31st and any subsequent visit annually. 

Massachusetts Mass. Gen. Laws Ch. §§175.47B, 176G.4M, and 

Insurers offering group blanket or general accident and sickness insurance policies, HMOs, 

“Biologically based mental disorders” means the following disorders as defined in the DSM: • schizophrenia; 

Mental health coverage requirements: Requires affecttal health benefits on a non-discriminatory basis for the dbiologically based mental disorders. • Also applies to rape-related disorders and to childre
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 37 

State law Applicability Definitions Major provisions 

32A.22 Effective 1996 (for state employee plans) and 2001 (for other entities) Amended 2008 

and individual accident and sickness policies. Also applies to group insurance commission coverage (the state employee plan). 

• schizo-affective disorder; • major depressive disorder; • bipolar disorder; • paranoia and other psychotic 

disorders; 

• obsessive-compulsive disorder; • panic disorder; • delirium and dementia; • affective disorders; • affective disorders; • eating disorders; • post traumatic stress disorder; • substance abuse disorders; 

and 

• autism. 

age of 19 for the diagnosis and treatment of non-biobehavioral, or emotional disorders as described in thly interfere with or limit the functioning and social ior adolescent. 

Scope of coverage: Prohibits differences in annual and ltween physical and outlined mental disorders. • Requires coverage of medically necessary care for 6

ment and a minimum of 24 outpatient visits annuall

• Requires benefits to consist of a range of inpatient, 

services that permit medically necessary and active ment for outlined mental disorders to take place in tly appropriate setting. 

• Permits services to be obtained from a general hosp

mental health services, private mental hospital, subsmunity based detoxification center, acute residentialization, day treatment and crisis stabilization licenspartment of public health or the department of ment

Massachusetts Mass. Gen. Laws Ch. §175.110(H) Effective 1991 

Any blanket or general policy of insurance. 

No definitions. Substance abuse coverage requirements: Requires aff

benefits for expenses arising from treatment of alcoholisScope of coverage: Requires the following minimum co• 30 days annually for inpatient care with an accredite

detoxification or rehabilitation services; and 

• $500 dollars annually for outpatient care at an accre

or public/private facility with rehabilitation services

Michigan Mich. Comp. Laws §500.3425 Effective 1982 

Group and individual insurers offering health insurance. 

“Substance abuse” means the taking of alcohol or other drugs: • at dosages that place an individual’s social, economic, 

psychological, and physical welfare in potential hazard; or 

• to the extent that an individual loses the power of selfSubstance abuse parity requirements: Requires affect

erage for intermediate and outpatient care for substance • Prohibits charges, terms, and conditions for required 

favorable than the maximum prescribed for any othe

Scope of coverage: Imposes minimum coverage of $1,5outpatient care for substance abuse annually. • Clarifies that provisions do not prohibit deductibles 

for intermediate and outpatient care for substance ab
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

control as a result of the use of alcohol or drugs, or while habitually under the influence of alcohol or drugs, endangers public health, morals, safety, or welfare, or a combination thereof. 

Exemption for cost increases: In the case of group insupolicyholder to decline coverage if the premium for the 

by 3% percent or more because of the required coverage• In the case of individual policies, allows the named 

if the premium for all individual health insurance pobe increased by 3% or more because of the required 

Michigan Mich. Comp. Laws §500.3501 Effective 2001 

HMOs. No definitions. Mental health and substance abuse parity requireme

terms, and conditions for the services required from beinmaximum prescribed for any other comparable service. Scope of coverage: Requires coverage to include 20 outmental health and a minimum of $2,968 in services for icare for substance abuse each year. • Provides for the annual adjustment of the minimum 

each year in accordance with the annual average percrease in the CPI. 

Exemption for cost increases: Permits a group subscrib

services if fees for the group contract would increase by provision of such services. 

Minnesota Minn. Stat. §62A.149 Effective 1986

Insurers and non-profit health service plan corporations offering group accident and sickness policies contracts and policies of accident and individual policies. 

No definitions. Substance abuse parity requirements: Requires affect

fits for the treatment of alcoholism, chemical dependencsame basis as for other benefits when treatment is renderresidential treatment program licensed in Minnesota purommendation by a doctor of medicine, or a nonresidentiproved or licensed in Minnesota. Scope of coverage: Requires coverage for hospital and rgrams to be at least 20% of the total patient days allowed than 28 days annually. • Requires coverage in a nonresidential treatment pro

annually. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 39 

State law Applicability Definitions Major provisions 

Minnesota Minn. Stat. §62Q.47 Effective 1995 

Nonprofit health service plan corporations issuing group or individual policies of accident and health insurance. Does not apply to policies providing per diem, fixed indemnity, nonexpense incurred, or accident-only coverage. 

No definitions. Mental health and substance abuse parity requireme

plans that provide coverage for mental health or chemicaprovide inpatient and outpatient services for such treatmgreater financial burden on the insured or enrollee, or ththose requirements and limitations for other inpatient an• Allows an individual under individual coverage to e

benefits in exchange for an appropriate reduction in 

Mississippi Miss. Code Ann. §§83-9-27 and 83-9-31 Effective 1975 

Any group coverage offered by accident or sickness insurers or nonprofit health plan corporations. Does not apply to individual policies. 

“Alcoholism” is defined as the chronic and habitual use of alcoholic beverages by any person to the extent that such person has lost the power of self-control with respect to the use of such beverages. 

Substance abuse coverage requirements: Requires affreimbursement for care and treatment of alcoholism in thsulting from sickness, or from bodily injury by accidentaScope of coverage: Prohibits coverage from exceeding year. • Extends benefits only to treatment and services rend

hospitals licensed by the state where the service is r

Mississippi Miss. Code Ann. §83-9-39 Effective 2002 

All alternative delivery systems and individual and group health insurance policies that do not offer mental health benefits. Does not apply to specified disease and other limited benefit health insurance policies. 

No definitions. Mental health coverage requirements: Requires affect

100 eligible employees to provide covered benefits for thness. • Requires affected entities of 100 or fewer eligible em

als to offer benefits for the treatment of mental illnepolicy may reject in writing. 

Scope of coverage: Requires benefits to include inpatiencertified as necessary by a provider. • Requires health service providers to certify that an i

mental illness and refer such individual for the apprindividual may qualify to receive benefits. 

• Requires the exclusion for coverage of a pre-existin

the same period of time as that for other medical illnsame plan, program or contract. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Benefit management: Requires all mental illness treatmject to professional utilization and peer-review procedurExemption for cost increases: Exempts coverage for trthe application of these provisions results in an increase or coverage of 1%or more. 

Missouri Mo. Rev. Stat. §376.1550 Effective 2005 

Health carriers offering or issuing health benefit plans, including those offered to state employees. Does not apply to individual coverage or supplemental insurance policies, including life, accident-only, specified disease, hospital policies providing a fixed daily benefit only, Medicare supplement, longterm care, hospitalization-surgical, or any other supplemental policy determined by the DOI. 

“Mental health condition” means any condition or disorder defined by categories listed in the most recent edition of the DSM, except for chemical dependency. 

Mental health parity requirements: Requires affected age for a mental health condition and prohibits the estabor condition that places a greater financial burden on an ment for a mental health condition than for access to treacondition. Scope of coverage: Requires any deductible or out-of-phensive for coverage of all health conditions whether meBenefit management: Permits mental health benefits to naged care program. • Permits covered services to be delivered through a s

rangements with one or more providers, hospitals, rtreatment programs. 

Exemption for cost increases: Permits coverage for treconditions to be waived if a policyholder can demonstraover any consecutive 24-month period that compliance ipremium by 2% or more. 

Missouri Mo. Rev. Stat. §§376.826, 376.827, 376.830, 376.833 and 376.836 Effective 2000 Amended 2004 

Insurers providing group and individual health insurance policies. Does not apply to supplemental insurance policies, including life, accident-only, specified 

“Mental illness” means the following disorders in the ICD-9: • schizophrenic disorders and 

paranoid states; 

• major depression; • bipolar disorder and other 

affective psychoses; 

• obsessive compulsive disorders; 

Mental health mandated offer requirements: Requirecoverage for mental illnesses, including substance abuseother illnesses, with certain exceptions such as limits on days for treatment of substance abuse or mental illness. • When read together with the requirements of §24.37

a policyholder who rejects the offer to opt for more 

• Requires a health insurance policy covering at least 

under mental illness, to cover all of the illnesses list

• Prohibits the establishment of any rate, term or cond
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 41 

State law Applicability Definitions Major provisions 

Sunset 01/01/11 disease, hospital policies providing a fixed 

daily benefit only, Medicare supplement, longterm care, hospitalization-surgical, or any other supplemental policy determined by the DOI. 

• post-traumatic distress and 

other anxiety disorders; 

• early childhood psychoses 

and other disorders first diagnosed in childhood or adolescence; 

• alcohol and drugs abuse; • anorexia nervosa, bulimia 

and other severe eating disorders; and 

• senile organic psychotic conditions. The term does not include chemical dependency. 

financial burden for treatment and evaluation of meplaced on the enrollee for treatment and evaluation 

Scope of coverage: Prohibits deductibles, co-pays, or coaccess to evaluation and treatment for mental illness from relation to the cost of services provided. • Requires alcohol and other drug abuse services to h

inpatient treatment and 20 total outpatient visits for 

• Permits a lifetime limit equal to four times such ann

for alcohol and drug abuse. 

• Permits the days for inpatient treatment for alcohol 

verted for use for outpatient treatment on a 2:1 basis

Benefit management: Permits coverage to be provided program established by the affected entity. • Permits covered services to be delivered through a s

rangements with one or more licensed providers, cohospitals, nonresidential or residential treatment prohealth service delivery entities certified by the depaaccredited by a nationally recognized organization, 

Missouri Mo. Rev. Stat. §§376.810 and.376.811 Effective 1997 Amended 2004

Chemical dependency provisions apply to every insurance company and health services corporation doing business in the state. Mental health provisions apply to every insurance company, health services corporation, and HMO doing business in the state. None of the provisions apply to supplemental insurance policies, in-

“Recognized mental illness”means those conditions classified as “mental disorders” in the DSM, but does not include mental retardation. “Chemical dependency” means the psychological or physiological dependence upon and abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both. 

Mental health mandated offer requirements: Requirecoverage for recognized mental illness, excluding chemi• If the policyholder rejects the offer, provides that th

verned by §§24.376.825 to 24.376.835 (see above). 

Scope of mental health coverage: Requires minimum cclude: 

 outpatient treatment, including treatment throug

gram services for a recognized mental illness thcensed professional; 

 residential treatment programs for the therapeu

recognized mental illness when prescribed by a rendered in a psychiatric residential treatment cpartment of mental health or accredited by the Jcreditation of Hospitals to the same extent as an

 up to 90 days annually of inpatient hospital trea

mental illness to the same extent as for other ill
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

cluding life, accidentonly, specified disease, hospital policies providing a fixed daily benefit only, Medicare supplement, long-term care, hospitalizationsurgical, or any other supplemental policy determined by the DOI. 

• Requires coverage to be subject to the same coinsur

annual maximum, and lifetime maximum factors as 

• Requires at least 2 sessions per year with a licensed 

chologist, licensed professional counselor, or licensacting within the scope of such license.  Requires such coverage to be for diagnosis or a Prohibits coverage from being subject to any pr Requires the same coinsurance, co-pay, and ded

regular office visits for mental health benefits a

Benefit management of mental health coverage: Perm

to be offered through a managed care program. • Permits covered services to be delivered through a s

rangements with one or more providers, hospitals, rtreatment programs. 

Substance abuse mandated offer requirements: Requfer coverage for chemical dependency. Scope of substance abuse coverage: Requires minimum clude: 

 26 days of outpatient treatment through a nonre

gram or through partial or full day program serv

 21 days of inpatient residential treatment per be 6 days of detoxification in a medical or social s

• Permits a separate lifetime cap of 10 episodes of tre

detoxification in a life-threatening situation as detersician and subsequently documented within 48 hour

sonable satisfaction of the affected entity. 

• Requires coverage to be subject to the same coinsur

ductible factors as those that apply to physical illnes

Benefit management of substance abuse coverage: Peefits to be offered through a managed care program. • Permits services to be delivered through a system of 

with one or more providers, hospitals, residential or programs, or other mental health service delivery enpartment of mental health or accredited by a nationation, or licensed by the state. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 43 

State law Applicability Definitions Major provisions 

Missouri Mo. Rev. Stat. §376.779 Effective 1995 Amended 2004 

Individually underwritten health plans or policies which provide hospital treatment. Does not apply to supplemental insurance policies, including life, accident-only, specified disease, and hospital policies providing a fixed daily benefit only, Medicare supplement, long-term care, shortterm major medical of less than 6 months. 

No definitions. Substance abuse parity requirements: Requires affect

erage, while confided in a hospital or residential or nonrby the Department of Mental Health, for treatment for trthe same basis as for coverage for any other illness. Scope of coverage: Permits coverage to be limited to a tcy or contract period for all levels of care. 

Montana Mont. Code Ann. §33-22-706 [as amended by S.B. 234 (2009)] Effective 2000 Amended 2009 

HMOs, individual and group health and disability insurers3, individual and group hospital 

and medical expense insurers, medical subscriber contracts, membership contracts of a health service corporation, and the comprehensive health association. Does not apply to: • blanket, short-term 

travel, accident-

“Severe mental illness” means the following disorders as defined in the DSM: • schizophrenia; • schizoaffective disorder; • bipolar disorder; • major depression; • panic disorder; • obsessive-compulsive disorder; and • autism. 

Mental health parity requirements: Requires affected 

of benefits for the necessary care and treatment of severe less favorable than that level provided for other physical 

Scope of coverage: Requires benefits to include: 

 inpatient hospital services; 

 outpatient services;  rehabilitative services;  medication; and  services rendered by certain licensed health car

licensed advanced practice RNs with prescriptiing in mental health). 

• Requires benefits for severe mental illness to be inc

maximum lifetime benefits, co-pays and deductibles

• Requires coverage for a child with autism who is 18 

comply with the mental health coverage parity requ

3 In Montana, health insurance is known as “disability insurance.” For more information, see AHIP’s Disability Income Protection and 

 Definitions chart.
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 44 

State law Applicability Definitions Major provisions 

only, limited or specified disease policies; 

• individual conversion policies or 

contracts; or 

• policies or contracts designed for 

issuance to persons eligible for coverage under Medicare, or any other similar coverage under state or federal governmental plans. 

agnosed with autistic disorder, Asperger’s disorder, tal disorder not otherwise specified. 

Benefit management: Permits benefits to be subject to 

contained in the policy or certificate. 

Montana Mont. Code Ann. §33-22-703 Effective 2001 

Insurers, health service corporations, and all employees' health and welfare funds issuing accident and health group policies and certificates or group subscriber contracts. Does not apply to: • blanket, short-term 

travel, accidentonly, limited or specified disease policies; 

• individual conversion policies or 

contracts; or 

• policies or contracts designed for 

issuance to persons 

No definitions. Mental health and substance abuse coverage requirem

entities to provide for the necessary care and treatment oism, and drug addiction. • Requires affected entities to provide for the necessa

mental illness, alcoholism, and drug addiction, undecontracts, inpatient and outpatient benefits consistinlar limits, deductibles, and coinsurance factors. 

Scope of coverage: Requires the following minimum co• inpatient treatment for mental illness of 21 days ann

• inpatient treatment for mental illness may be traded 

for partial hospitalization through a program that cofor a partial hospitalization program as published by for Partial Hospitalization if the program is operated 

• inpatient and outpatient treatment for alcoholism an

costs for medical detoxification, up to $6,000 annuamum inpatient benefit of $12,000 is met, after whicreduced to $2,000; 

• costs for medical detoxification treatment paid the s

and 

• outpatient treatment under major medical of $2,000 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 45 

State law Applicability Definitions Major provisions 

eligible for coverage under Medicare, or any other similar coverage under state or federal governmental plans. 

Montana Mont. Code Ann.§53-21-132Effective 2005 

Private insurance carriers and public assistance programs. No definitions. Mental health coverage requirements: Requires affect

erage of the cost(s) associated with pre-commitment psynation, and treatment for a person who is suffering from requires commitment to a mental health facility. 

Nebraska Neb. Rev. Stat. §44-769, et. seq. Effective 1980 

Insurers offering group sickness and accident insurance and HMOs. 

“Outpatient treatment” means counseling and therapy provided on a nonresidential basis when such treatment is rendered in or through a hospital, a substance abuse treatment center, or an outpatient program which is certified or accredited to render such care. 

Substance abuse mandated offer requirements: Requ

do not provide basic coverage for the treatment of alcohin written sales and advertising literature, descriptive bro

provisions in the policy, contract or certificate that “This vide basic coverage for the treatment of alcoholism. Cocoholism is available if you specifically request it and thand conditions as you and the company agree.” 

• Prohibits the use of the term “comprehensive” in wr

literature, descriptive brochures, and the policy or c

Scope of coverage: Requires benefits to be provided untions as may be agreed upon between the subscriber/insu• Deems the following benefits as providing basic cov

alcoholism if provided on terms involving durationaductibles, and coinsurance which are no less favorabit makes benefits available for the treatment of phys 30 inpatient days annually with at least 2 treatm

and 

 60 outpatient visits during the lifetime of the po

• Prohibits co-pays, coinsurance, dollar or lifetime lim

that are less favorable generally than for physical ill
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 46 

State law Applicability Definitions Major provisions 

Nebraska Neb. Rev. Stat. §44-791, et. seq. Effective 2000 

Group health insurance plans, group HMO contracts, group subscriber contracts, and any selffunded employee benefit plan, to the extent not preempted by federal law. • The term includes 

group policies, contracts, and/or plans offered or administered by the state or its political subdivisions. 

Does not apply to group policies providing coverage for a specified disease, accident-only coverage, hospital indemnity coverage, disability income coverage, Medicare supplement coverage, longterm care coverage, or other limited-benefit coverage. Does not apply to any plan covering an employer group with fewer than 15 employees. 

“Mental health condition” means any condition or disorder involving mental illness that falls under any of the diagnostic categories listed in the Mental Disorders Section of the ICD.“Rate, term, or condition” means lifetime limits, annual payment limits, and inpatient or outpatient service limits. • Does not include any deductibles, co-pays, or coinsurance. “Serious mental illness” means any condition that current medical science affirms is caused by a biological disorder of the brain and that substantially limits life activities. Includes, but is not limited to: • schizophrenia; • schizoaffective disorder; • delusional disorder; • bipolar affective disorder; • major depression; and • obsessive compulsive disorder. 

Mental health parity requirements: Does not require cconditions or serious mental illnesses. • Prohibits affected entities providing coverage for th

health conditions other than alcohol or substance abrate, term or condition that places a greater financiaaccess to treatment of serious mental illness than fophysical health condition. 

 If no coverage is provided for serious mental health 

fit materials to contain a clear and prominently plac

coverage. 

Scope of coverage: Requires out-of-pocket limits to be limit for coverage of both mental health conditions and p• Requires health insurance plans providing coverage 

to cover health care rendered for treatment of seriou

tal health professional, by a person authorized by Dcensure to provide treatment for mental illness, in a any other licensed institution or facility providing msuant to a written plan. 

Benefit management: Permits affected entities to manacommon methods, including, but not limited to, preadmithorization of services, or other mechanisms designed to for mental health conditions that are deemed to be mediccally appropriate. • Allows for management of benefits through commo

not limited to, preadmission screening, prior authorimechanisms designed to limit coverage to services fthat are deemed to be medically necessary and clini

• Permits an affected entity to use a case managemen

organization to evaluate, determine, and provide or cessary and clinically appropriate care and treatmenmental health condition or serious mental illness wh

• Allows affected entities to require a provider who re

mental illnesses to enter into a contract as a conditio

• Provides that nothing prohibits an affected entity fro

reimbursement rates and service delivery systems, ito, mental health carve-out programs even if the plaoptions for the treatment of physical conditions. 
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State law Applicability Definitions Major provisions 

Out-of-network services: Does not require coverage foprovided by out-of-network providers. Rule of construction: Clarifies that nothing requires an the same rates, terms, or conditions between treatments and preventive care. • Provides that an affected entity is not in violation of 

plan applies different rates, terms, and conditions or coverage the following: 

 marital, family, educational, developmental, or  care that is substantially custodial in nature;  services and supplies that are not medically nec

priate; or 

 experimental treatments. 

Nevada Nev. Rev. Stat. §§57.689B.036 and 57.695C.174 Effective 1998 Amended 1999 

Group health insurers. No definitions. Substance abuse parity requirements: Requires affect

same coverage for the treatment of the abuse of alcohol covered illness. Scope of coverage: Requires the following minimum be

 treatment for withdrawal from the physiologica

drugs of $1,500 per calendar year; 

 treatment for a patient admitted to a facility of $

and 

 counseling for a person, group or family who is 

of $2,500 per calendar year. 

• Permits benefits to be received in any facility for th

cohol or drugs which is certified by the health divisifacility or facility for the dependent which is licenseaccredited by the Joint Commission on Accreditatiovides a program for the treatment of abuse of alcohocredited activities. 

Nevada Nev. Rev. Stat. §57-689B-0359 

Group health insurers. Does not apply to 

“Severe mental illness” means any of the following mental illnesses that are biologically based 

Mental health coverage requirement: Requires affecterage for the treatment of severe mental illness. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Effective 2000 

groups with fewer than 25 employees. 

and for which diagnostic criteria are prescribed in the DSM-IV: • schizophrenia; • schizo-affective disorder; • bipolar disorder; • major depressive disorders; • panic disorder; and • obsessive-compulsive disorder. 

Scope of coverage: Requires coverage for: 

 40 days of hospitalization as an inpatient per po

 40 visits of outpatient treatment per policy year

management of medication; and 

 two visits for partial or respite care per policy y

tuted for each one unused day of hospitalization 

• Provides that the required coverage does not include 

rehabilitation or care received as a custodial inpatien

• Prohibits any deductibles and co-pays required 

mental illness from being greater than 150% of required to be paid for medical/surgical benefits

Exemption for cost increases: Allows affected entities Commissioner for an exemption from these requirementthe policy, or a standard grouping of policies, increases bsult of providing the required coverage. 

New Hampshire N.H. Rev. Stat. Ann. §415.18-a Effective 1993 

Insurers offering group or blanket accident or health insurance providing benefits for medical or hospital expenses, and HMOs. 

"Mental or nervous conditions" or "mental illness and emotional disorders" means mental disorders, as defined in the most recent edition of DSM, excluding those disorders designated by a "V Code" and those disorders designated as criteria sets and axes provided for further study in the DSM. The term does not include chemical dependency, including alcoholism. 

Mental health parity requirement: Requires affected efor expenses arising from the treatment of mental illnessat least as favorable as for other illnesses. • Requires affected entities to offer to each group the 

separate and identifiable premium, additional coveras a result of treatment or counseling by a licensed c

Scope of coverage: For coverage for mental illnesses anmajor medical plan, requires benefits to be: 

 subject to terms and conditions at least as favor

services for other illnesses; and 

 provided in a ratio of benefits to the fees charge

ratio as for other illnesses. 

• For coverage for mental illnesses and disorders und

requires:  for outpatient services, a minimum of 15 hours

 for all other services, at least $3,000 per year an

and 

 for co-payments and deductibles, application of 

than those that apply for other illnesses. 

• Prohibits any policy provision that denies benefits f
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

logical services, including psychological examinatiorendered to an insured or a dependent in compliance any court of this state. 

Substance abuse coverage requirements: Requires ponesses and disorders to include coverage for expenses archemical dependency, including alcoholism, up to a specdefined in terms of a dollar amount or a maximum numb• Requires such coverage to include both an inpatient 

for detoxification and rehabilitation. 

New Hampshire N.H. Rev. Stat. Ann. §37.417-E:1 Effective 1995 

Insurers offering group or blanket accident or health insurance, nonprofit health service corporations, and HMOs. 

“Mental illness” means a clinically significant or psychological syndrome or pattern that occurs in a person and that is associated with present distress, a painful symptom or disability, impairment in one or more important areas of functioning, or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. “Mental illness” includes the following biologically based mental illnesses, as defined in the most current edition of the DSM: • schizophrenia; • schizoaffective disorder; • major depressive disorder; • bipolar disorder; • paranoia and other psychotic 

disorders; 

• obsessive-compulsive disorder; • panic disorder; and • pervasive developmental disorder or autism. 

Mental health parity requirement: Requires affected efor disease or sickness to provide benefits for treatment biologically-based mental illnesses under the same termare not less extensive than coverage provided for any othphysical illness. 
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State law Applicability Definitions Major provisions 

New Jersey N.J. Stat. Ann. §17B:27-46.1 Effective 1985 Amended 1997 

Insures offering group health insurance policies providing hospital or medical expense benefits. 

No definitions. Substance abuse parity requirement: Requires affecte

age for expenses incurred in connection with the treatmesuch treatment is prescribed by a doctor. • Requires such benefits to be provided to the same ex

ness under the contract. 

Scope of coverage: Requires such coverage to include in a licensed hospital that meets minimum standards of cprescribed by the Joint Commission on Accreditation of a detoxification licensed facility. 

New Jersey N.J. Stat. Ann. §17B:27-46.1v Effective 1999 Amended 2005 N.J. Admin. Code §11:4-57.1 to 11:4-57.4 Readopted 2006 

Insurers offering group health insurance policies providing hospital or medical expense benefits. 

“Biologically based mental illness” means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to: • schizophrenia; • schizo-affective disorder; • major depressive disorder; • bipolar disorder; • paranoia and other psychotic 

disorders; 

• obsessive-compulsive disorder; • panic disorder; and • pervasive developmental disorder or autism. 

Mental health parity requirements: Requires affected for biologically based mental illness under the same termspect to co-payments, deductibles, or benefit limits as prness under the policy. • Prohibits affected entities from applying any exclus

services or supplies that are medically necessary for persons with biologically based mental illness, to thsupplies are not experimental or investigational. 

Scope of coverage: Prohibits exclusions or denials of be

not limited to: 

 treatment for chronic conditions; 

 physical, speech and occupational therapy that 

 services rendered after a fixed period of time ha

procedure, or the onset of illness; 

 treatment of developmental disorders or develo

 therapy on a long-term basis; 

 treatment of behavioral problems; and 

 treatment of learning disabilities. 

• Requires affected entities to apply benefit limits, inc

requirements and visit limits, to the treatment of bioillness to the same extent as those applied on physic Permits visit limits to be applied for the treatme

mental illness if the same visit limits are appliement of physical illness. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

o For example, a limit of 30 speech therapy v

for speech therapy to treat a biologically bas autism or pervasive developmental disorplies to speech therapy to treat a physical i

 Prohibits blanket preauthorization requirements 

biologically-based mental illness. 

 Permits preauthorization of particular services f

logically based mental illness only if preauthorisame or similar services when provided to treat 

o For example, a carrier may require preauth

hospitalization for the treatment of biologicif it also requires preauthorization of intensfor physical illness such as outpatient surgeiation therapy. 

Benefit management: Allows insurers to continue usuaing the medical necessity of services. • Permits insurers to determine which providers are e

for providing services for mental illnesses under the 

New Mexico N.M. Stat. Ann. §59A-23-6 Effective 1983 

Group health insurers. No definitions. Substance abuse mandated offer requirements: Requ

fer coverage and make available benefits for the necessaalcohol dependency with the same annual deductibles anments for other benefits within the same policy. • Requires benefits to be subject to the rights of the g

the coverage of to select any alternative level of ben

Scope of coverage: Requires coverage to include a minitient and outpatient treatment. • Requires benefits to be offered for benefit periods o

prohibits a lifetime maximum of less than 2 benefit 

New Mexico N.M. Stat. Ann. §59A-23E-18 Effective 2000 

Group health plans. “Mental health benefits” means 

mental health benefits as described by the group health plan offered in connection with the plan. 

Mental health parity requirements: Requires affected medical/surgical benefits and mental health benefits. • Prohibits an affected entity from imposing treatmen

requirements on the provision of mental health beneor requirements are not imposed on coverage of ben
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

• The term does not mean benefits with respect to substance abuse, chemical dependency, or gambling addiction. Benefit management: Permits affected entities to: • require pre-admission screening prior to authorizatio

whether inpatient or outpatient; and • apply limitations that restrict mental health benefits those that are medically necessary. 

Exemption for cost increases: If a policyholder with feperiences a premium increase of more than 11⁄2%in a placoverage or a policyholder with 50 or more employees ecrease of more than 21⁄2 % in a plan year due to the chanholder may either: • pay the premium increase excess; • reach agreement with the employees to cost-share th

increase excess; 

• negotiate a reduction in coverage, but not below the 

the renewal to reduce the premium increase excess; 

• after demonstrating that the amount of the excess pr

to the additional coverage required, receive written sion of insurance to not increase coverage. 

New York N.Y. Ins. Law §3221 Effective 2007 Sunsets 12/31/09 

Insurers delivering a group or school blanket policy, hospital and health service corporations, and medical expense indemnity policies Mandatory provision of coverage does not apply to group purchasers with 50 or fewer employees. Group purchasers with 50 or fewer employees must offer the coverage required. 

“Biologically based mental illness” means a mental, nervous, or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. • Such biologically based mental illnesses are defined as: 

 schizophrenia/psychotic 

disorders; 

 major depression;  bi-polar disorder;  delusional disorders;  panic disorders; 

Mental health parity requirements: Requires affected based coverage for the diagnosis and treatment of mentadisorders or ailments, however defined in such policy, at provided for other health conditions. • Requires affected entities providing coverage for in

physician services to provide comparable coverage children with biologically based mental illness and ctional disturbance comparable to the medical coveraicy. 

Scope of coverage: Requires coverage for the diagnosis nervous, or emotional disorders or ailments to include bea hospital. 

 Permits such benefits to be limited to not less tha

ment in any contract, plan, or calendar year. 

• Requires coverage for the diagnosis and treatment o

tional disorders or ailments to include outpatient car
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

 obsessive compulsive 

disorders; 

 bulimia and anorexia. 

“Children with serious emotional disturbances” means persons under the age of 18 years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive developmental disorders, and where there are one or more of the following: • serious suicidal symptoms or 

other life-threatening selfdestructive behaviors; 

• significant psychotic symptoms (hallucinations, delusional, bizarre behaviors); • behavior caused by emotional 

disturbances that placed the child at risk of causing persona injury or significant property damage; or 

• behavior caused by emotional 

disturbances that placed the child at risk of causing personal injury or significant property damage; or 

• behavior caused by emotional 

disturbances that placed the child at substantial risk of removal from the household. 

erating certificate by the commissioner of mental heed by the office of mental health, or by a psychiatristo practice in this state or a professional corporation 

tice corporation. 

 Permits benefits to be limited to not less than 20 

or calendar year. 

• Allows partial hospitalization program benefits to o

at a ratio of 2 partial hospitalization visits to 1 inpat

• Permits coverage for the diagnosis and treatment of 

tional disorders or ailments to be subject to annual dinsurance as may be deemed appropriate by the suptent with those imposed on other benefits within a g

• Requires coverage for biologically based mental illn

al disturbances to be provided under the terms and ccable under the policy, including network limitationco-pays, co-insurance, deductibles, or other specific 

• Permits coverage for biologically based mental illne

disturbance through networks to have different co-inductibles for out-of-network benefits, regardless of ten under one license or two. 

Benefit management: Nothing shall be construed as preagement or utilization review of mental health benefits, pective, concurrent, or retrospective utilization review, ppropriateness criteria as to the level and intensity of treavioral health. • Nothing shall be construed as preventing a policy fr

through a network of participating providers who mparticipation, including provider credentialing. 

Cost report: Requires the superintendent, in consultatiohealth, to study the effectiveness of mental health parity• Requires the study to be completed and sent to the l

and include, but not be limited to:  a comprehensive analysis of the costs associate

age pursuant to this act; 

 the number of policyholders and group contract 

elected to purchase other mental health coveravailable pursuant to this act; and 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

 a comparison of the type and number of illnesse

been provided during the study period. 

North Carolina N.C. Gen. Stat. §58-51-50 Effective 1985 Amended 1991 

Group insurance or blanket accident and health insurers. 

“Chemical dependency” means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. 

Substance abuse mandated offer requirements: Requfer benefits for the necessary care and treatment of chemnot less favorable than benefits for physical illness gener• Requires a rejection of such offer to be in writing. 

Scope of coverage: Requires benefits for chemical depesame durational limits, dollar limits, deductibles, and co

benefits for physical illness. • Requires contracts to provide for $8,000 worth of b

period, and a lifetime minimum benefit of $16,000. 

• Requires coverage of the following providers: 

 chemical dependency, medical, and psychiatric 

 chemical dependency units in psychiatric hospi

 residential chemical dependency treatment faci

 social setting detoxification facilities or program

 medical detoxification or programs; and 

 licensed physicians, and duly licensed practicin

North Carolina N.C. Gen. Stat. §135-40.7B Effective 2000 

State employee benefit plans and CHIP. 

“Mental illness” means: • with respect to an adult, an 

illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his/her affairs and social relations as to make it necessary or advisable for him/her to be under treatment, care supervision, guidance, or control; and 

• with respect to a minor, a 

mental health condition, other than mental retardation alone, that so impairs the 

Mental health and substance abuse parity requireme

mental illness and chemical dependency to be subject to rational limits, and coinsurance factors as are benefits foally. Scope of coverage: Requires affected entities to provide and professional charges for inpatient care, outpatient caprogram services, partial hospitalization treatment, and rment. • Establishes a list of facilities in which mental illness 

treatment may be provided. Provides a list of the prnecessary care and treatment of mental illness and c

Benefit management: Requires mental illness and chemto be subject to case management programs for medical ness. 
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State law Applicability Definitions Major provisions 

youth’s capacity to exercise age adequate self-control or judgment in conduct of his/her activities and social relationships so that he/she is in need of treatment. 

“Chemical dependency” means the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal. 

North Carolina N.C. Gen. Stat. §§58-51-55; 58-65-90; and 58-67-70, 58-67-75, and 122C-3(21) Effective 1989 Amended 2007

Any group insurance contracts; hospital, medical and dental service corporations, and HMOs. 

“Mental illness” means: • when applied to an adult, an 

illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance, or control; and 

• when applied to a minor, a 

mental condition, other than mental retardation alone, that so impairs the youth's capacity to exercise age adequate self-control or judgment in the conduct of his activities and social relationships so that he is in need of treatMental health and substance abuse coverage requirem

entities from taking the below actions solely because an has or had a mental illness or chemical dependency:  refuse to issue or deliver to that individual any 

or coverages for any medical treatment or serviinjury;  have a higher premium rate or charge for physirages or benefits for that individual; or  reduce physical illness or injury coverages or b

• Does not require affected entities to offer coverage • Prohibits HMOs providing mental health benefits fr

time or annual dollar limitation on such benefits thajury benefits. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

ment, 

with a mental disorder defined in the DSM, except those mental disorders coded in the DSM as substance related, as sexual dysfunctions, and those coded as “V” codes. "Chemical dependency" means 

the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal, with a mental disorder defined in the DSM. 

North CarolinaN.C. Gen. Stat. §§58-3-220 and 58-50-155 Effective 2008 

Group health benefit plans and standard health plans offered to small employers 

“Mental illness” means • when applied to an adult, an 

illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance, or control; and 

• when applied to a minor, a 

mental condition, other than mental retardation alone, that so impairs the youth's capacity to exercise age adequate self-control or judgment in the conduct of his activities 

Mental health parity requirements: Requires affected age for the necessary care and treatment of mental illnesble than those for physical illness, including limits to coScope of coverage: Requires affected entities to provide inpatient and outpatient days per year as well as 30 offic• Permits durational limits on mental illnesses that dif

on physical illnesses, except for the following ment bipolar disorder;  major depressive disorder;  obsessive compulsive disorder;  paranoid and other psychotic disorders;  schizoaffective disorder;  schizophrenia;  post-traumatic stress disorder; and  anorexia and bulimia. 

• Permits annual limits, lifetime limits, co-pays, dedu

made applicable to the mental health benefits based the benefits provided for physical health benefits wh
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

and social relationships so that he is in need of treatment. 

“Mental disorder” means disorders defined in the most recent edition of the DSM, except those mental disorders coded as substance-related disorders , those coded as sexual dysfunctions , and those coded as 'V' codes. “Limits” includes deductibles, coinsurance, co-pays, maximum out-of-pocket limits, annual and lifetime dollar limits, and any other dollar limits or fees for covered services. 

annual limits, lifetime limits, co-pays, deductibles, olected physical illness and injury benefits that do noof the physical benefits of the plan. 

• Exempts the affected entities insurers from providin

studies leading to or in connection with sex changes lated care. 

Benefit management: Permits the affected entity to appria to determine medical necessity. 

North Dakota N.D. Cent. Code §26.1-36-09 Effective 2000 Amended 2007 

HMOs, insurance companies, and non-profit health service corporations in the group market. 

No definitions. Mental health parity requirements: Requires affected 

same type of benefits for mental health disorders as it dowhich meet or exceed the benefits described below. Scope of coverage: Requires a minimum benefit for inpper calendar year. • Requires partial hospitalization or residential treatm

days in any calendar year. Allows any individual recalendar days of residential treatment to trade up to tient treatment benefits. 

• Requires outpatient treatment for a minimum of 30 

if provided by specified providers. Prohibits applicpayment for the first five hours and a co-payment grmaining hours (unless services are provided by an owithout a referral). 

• Requires an affected entity to provide coverage for 

from suicide, attempted suicide, or self-inflicted inju

Benefit management: Allows an insurer to require “an 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

plan” from the inpatient provider which indicates that inmost appropriate and least restrictive form of treatment aty.” 

North Dakota N.D. Cent. Code §26.1-36-08 Effective 2001 

An insurance company, nonprofit health service corporation, or HMO issuing group health coverage. 

“Substance abuse” means alcoholism, drug addiction, or other related illnesses. 

Substance abuse coverage requirements: Prohibits affing, issuing, executing, or renewing any health insurance the policy or contract provides benefits, of the same type for the diagnosis, evaluation, and treatment of alcoholismrelated illness, which benefits meet or exceed the benefiScope of coverage: Requires affected entities to provide coverage: 

 60 days of inpatient treatment in any calendar y

pital offering substance abuse treatment; 

 120 days of partial hospitalization in any calend

similar center) providing substance abuse treatm

 20 outpatient visits treatment in any calendar ye

vided by a licensed physician (within his or her censed psychologist, or by a licensed addiction ble or co-payment for the first five outpatient vand no co-payments of more than 20% for the rservices are provided by an out-of-network proand 

 60 days of residential treatment in any calendar 

tial treatment facility; however, permits unused traded for residential treatment (generally, two ment equals one day of inpatient, up to 23 days

• Permits benefits to be provided for a combination o

pitalization with each day of inpatient treatment beitial hospitalization treatment (not to exceed 46 days hospitalization).

Ohio Ohio Rev. Code Ann. §3923.27Effective 1976 

Policies of sickness and accident insurance, including both individual and group policies, that provides hospitalization 

No definitions. Mental health coverage requirements: Prohibits affec

hospitalization coverage for mental illness shall exclude son that the insured is hospitalized in an institute or facilfrom the state, any municipal corporation, county, or joisuch institution or facility is deemed charitable or otherw
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Amended 2005 coverage for mental illness. tion or facility is fully accredited by the Joint Commissio

Hospitals or certified under federal law. Scope of coverage: Requires payment in an amount equthe full amount of the statutory charge for the cost of the §5121.33 of the Revised Code (governing the Departmebility for community health services) or the benefits paythe applicable policy. • Requires benefits to be paid so long as patients and 

responsible for payment under state law. 

• Limits payment to that portion or percent of the ben

signed, or ordered to be paid, to the state or other apvices rendered by the institution or facility. 

Ohio Ohio Rev. Code Ann. §3923.28 Effective 1980 Amended 2006

Group policies of sickness and accident insurance. Does not apply to policies providing coverage for specific diseases or accidents only. 

No definitions. Mental health coverage requirements: Requires affect

coverage for mental or emotional disorders to include beoutpatient basis for each eligible person under the policy for mental or emotional disorders or for evaluations. Scope of coverage: Mandates benefits that are at least edar year. • Requires the services to be legally performed by or 

of a licensed physician, licensed osteopath, licensed fessional clinical counselor, licensed professional codent social worker, licensed clinical nurse specialist mental health. 

• Mandates coverage whether performed in an office, 

munity mental health facility so long as the hospital health facility is approved by the Joint Commission Healthcare Organizations, the Council on Accreditaly Services, the Rehabilitation Accreditation Comm

Department of Mental Health as being in complianclished under state law. 

• Allows the benefits to be subject to reasonable cont

subject to reasonable deductibles and co-insurance c

• Limits benefits for persons entitled to coverage und

contract to a single $550 outpatient benefit. 
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State law Applicability Definitions Major provisions 

Benefit management: States that in order to be reimburmust comply with the following requirements: • the services must be performed in accordance with a 

scribes the expected duration, frequency, and type o

• the treatment plan shall be reviewed and approved b

sional every 3 months.

Rule of Construction: Provides that nothing shall be coer to pay benefits which are greater than usual, customar• States that the required benefits shall not be reduced 

quired under §3923.281 (see below) for the diagnosically based mental illnesses.

• Clarifies that these requirements do not apply to ben

treatment of biologically based mental illness. 

Ohio Ohio Rev. Code Ann. §3923.281 Effective 2007 Amended 2008

Policies of sickness and accident insurance Does not apply to longterm care, hospital indemnity, disability income, Medicare supplement plans, one-time limited duration policies of no longer than 6 months, workers’ compensation, Medicaid, or any policy that provides coverage to beneficiaries enrolled in the children's buy-in program established under state law. 

“Biologically based mental illness” means the following as defined in the most recent edition of the DSM: • schizophrenia; • schizoaffective disorder; • major depressive disorder; • bipolar disorder; • paranoia and other psychotic 

disorders; 

• obsessive-compulsive disorder; and • panic disorder. 

Mental health parity requirements: Requires coverage treatment of biologically based mental illnesses on the sas, with benefits no less extensive than, those provided fnosis of all other physical diseases and disorders, if both • the biologically based mental illness is clinically dia

sician authorized to practice medicine and surgery osurgery; a licensed psychologist; a licensed professcensed professional counselor, or licensed independcensed clinical nurse specialist whose nursing speci

• the prescribed treatment is not experimental or inve

its clinical effectiveness in accordance with general

dards. 

Scope of coverage: Applies the parity requirements to a

tions, including, but not limited to: coverage of inpatient tient services, and medication; maximum lifetime benefividual and family deductibles. Benefit management: Provides that nothing prohibits insuing the following actions: • negotiating separately with mental health care provi

bursement rates and the delivery of health care serv

• managing the provision of benefits for the diagnosis 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

ly based mental illnesses through the use of pre-admquiring beneficiaries to obtain authorization prior to use of any other mechanism designed to limit covertermined to be necessary. 

Exemption for cost: Provides an exemption from the coof the following apply: • the insurer submits documentation certified by an in

American Academy of Actuaries to the DOI showindiagnostic and treatment services for biologically baperiod of at least 6 months independently caused the and administrative expenses for the coverage of all disorders to increase by more than 1% per year; 

• the insurer submits a signed letter from an independ

can Academy of Actuaries to the DOI opining that tabove could reasonably justify an increase of more miums or rates charged by the insurer for the coveradiseases and disorders; and 

• the Superintendent of Insurance makes the followin

documentation and opinion submitted: 

 incurred claims for services for biologically bas

period of at least 6 months independently causeclaims and administrative expenses for the covediseases and disorders to increase by more than 

 the increase in costs reasonably justifies an incr

the annual premiums or rates charged by the insother physical diseases and disorders. 

Ohio Ohio Rev. Code Ann. §3923.282 Effective 2007 

Any private or public employer group selfinsurance plan that provides payment for health care benefits for other than specific diseases or accidents only, which benefits are not provided by contract with a sickness and ac-

“Biologically based mental illness” means the following as defined in the most recent edition of the DSM: • schizophrenia; • schizoaffective disorder; • major depressive disorder; • bipolar disorder; • paranoia and other psychotic 

disorders; 

Mental health parity requirements: Requires coverage treatment of biologically based mental illnesses on the sas, with benefits no less extensive than, those provided fnosis of all other physical diseases and disorders, if both • the biologically based mental illness is clinically dia

sician authorized to practice medicine and surgery osurgery; a licensed psychologist; a licensed professcensed professional counselor, or licensed independcensed clinical nurse specialist whose nursing speci

• the prescribed treatment is not experimental or inve
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

cident insurer or health insuring corporation. Does not apply if federal law supersedes, preempts, prohibits, or otherwise precludes its application to employer group self-insurance plans. Does not apply to longterm care, hospital indemnity, disability income, or Medicare supplement plans of health coverage, or to any other supplemental benefit plans. 

• obsessive-compulsive disorder; and • panic disorder. 

its clinical effectiveness in accordance with generaldards. 

Scope of coverage: Applies the parity requirements to a

tions, including, but not limited to: coverage of inpatient tient services, and medication; maximum lifetime benefividual and family deductibles. Benefit management: Provides that nothing prohibits e

pursuing the following actions: • negotiating separately with mental health care provi

bursement rates and the delivery of health care serv

• managing the provision of benefits for the diagnosis 

ly based mental illnesses through the use of pre-admquiring beneficiaries to obtain authorization prior to use of any other mechanism designed to limit covertermined to be necessary. 

Exemption for cost: Provides an exemption from the coof the following apply: • the employer submits documentation certified by an 

the American Academy of Actuaries to the DOI shofor diagnostic and treatment services for biologicalla period of at least 6 months independently caused tclaims and administrative expenses for the coverage eases and disorders to increase by more than 1% per 

• the Superintendent of Insurance determines that inc

for biologically based mental illnesses for a period opendently caused the employer’s costs for claims anfor the coverage of all other physical diseases and dmore than 1% per year. 

Ohio Ohio Rev. Code Ann. §3923.29 Effective 1978 Amended 2001

Group policies of sickness and accident insurance. Does not apply to policies that provide coverNo definitions. Substance abuse coverage requirements: Requires cov

person under the policy who resides in the state for outpmediate primary care benefits for alcoholism. Scope of coverage: Mandates that coverage is provided least equal to $550 in any calendar year or twelve month 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

age for specific diseases or accidents only. 

• Requires the services to be legally performed by or 

sion of a licensed physician or a licensed psycholog

• Mandates coverage whether performed in an office, 

nity mental health facility, or in an alcoholism treatmhospital, community mental health facility, or alcohapproved by the Joint Commission on Accreditation by the Department of Health. 

• Allows the mandated benefits to be subject to reaso

and may be subject to reasonable deductibles and co

• Limits benefits for persons entitled to coverage und

contract to a single $550 benefit. 

Benefit management: Requires a licensed physician or certify every 3 months that the patient needs to continue for a patient who receives treatment for alcoholism from alcoholism treatment facility to remain entitled to the maRule of Construction: Provides that nothing shall be coer to pay benefits which are greater than usual, customar

Ohio Ohio Rev. Code Ann. §3923.30 Effective 1978 Amended 2006

Every person, the state and any of its instrumentalities, any county, township, school district, or other political subdivisions and any of its instrumentalities, and any municipal corporation and any of its instrumentalities, which provides payment for benefits for any of its employees resident in this state, which benefits are not provided by contract with an insurer qualified to provide sickness and accident 

No definitions. Mental health coverage requirements: Requires affect

coverage for mental or emotional disorders to include beoutpatient basis for each eligible person under the policy for mental or emotional disorders or for evaluations. Scope of coverage for mental health benefits: Mandatequal to $550 in any calendar year. • Requires the services to be legally performed by or 

of a licensed physician, licensed osteopath, licensed fessional clinical counselor, licensed professional codent social worker, licensed clinical nurse specialist mental health. 

• Mandates coverage whether performed in an office, 

munity mental health facility so long as the hospital health facility is approved by the Joint Commission Healthcare Organizations, the Council on Accreditaly Services, the Rehabilitation Accreditation Comm

Department of Mental Health as being in complianc
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

insurance, or a health insuring corporation. 

lished under state law. 

• Allows the benefits to be subject to reasonable cont

subject to reasonable deductibles and co-insurance c

• Limits benefits for persons entitled to coverage und

contract to a single $550 outpatient benefit. 

Benefit management for mental health coverage: Stat

bursable, services provided must comply with the follow• the services must be performed in accordance with a 

scribes the expected duration, frequency, and type o

• the treatment plan shall be reviewed and approved b

sional every 3 months.

Rule of construction: Provides that nothing shall be coner to pay benefits which are greater than usual, customar

• States that the required benefits shall not be reduced 

quired under §3923.281 (see below) for the diagnosically based mental illnesses.

• Clarifies that these requirements do not apply to ben

treatment of biologically based mental illness.

Substance abuse parity requirements: Requires paym

ism treatment for outpatient, inpatient, and intermediate gible employee and dependent Scope of coverage for substance abuse benefits: Man

are no less than $550 in a 12 month period. • Requires the services to be legally performed by or 

of a licensed physician, licensed osteopath, licensed fessional clinical counselor, licensed professional codent social worker, licensed clinical nurse specialist 

mental health. 

• Mandates coverage whether performed in an office, 

munity mental health facility or alcoholism treatmenhospital, community mental health facility, or alcohapproved by the Joint Commission on Accreditation by the Department of Health. 

• Permits the benefits to be subject to reasonable limi

to reasonable deductibles and co-insurance costs. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Benefit management: Requires a health care professionmonths the patient's need for continued services perform

Oklahoma Okla. Stat. §§36-6060.10 through 36-6060.12 Effective 2000 

Health benefit plans including: group hospital or medical insurance coverage; not-forprofit hospital or medical service indemnity plans; prepaid health plans; HMOs; PPOs; state and education employees group insurance plans; MEWAs; and employer self-insured plans not exempt under ERISA. Does not apply to small employers (50 or fewer full-time employees). Does not apply to individual, specified disease, accidental death or dismemberment, Medicare supplement, workers compensation, long-term care, motor vehicle, or nursing home fixed indemnity policies. 

“Severe mental illness” means any of the following biologically based mental illness as defined in DSM: • schizophrenia; • bipolar disorder (manic depressive illness); • major depressive disorder; • panic disorder; • obsessive-compulsive disorder; and • schizoaffective disorder. 

Mental health parity requirements: Requires a health benefits for the treatment of severe mental illness. • Requires benefits to be equal to benefits for treatme

diseases and disorders, including but not limited to t

Scope of coverage: Requires coverage for treatment of clude but not be limited to: • coverage of inpatient hospital services for either 26 

covered illnesses (whichever is greater); 

• coverage of outpatient services; 

• coverage of medication; 

• maximum lifetime benefits; 

• co-pays; 

• coverage of home health visits; 

• individual and family deductibles; and 

• coinsurance. 

Benefit management: Requires coverage of severe menthe same pre-authorization and utilization review mechaconditions as all other physician diseases and disorders. Exemption for cost increases: Exempts a health benefi

coverage requirements, if, as calculated under a specifieriences a greater than two percent increase in premium cquired coverage. Penalties: Imposes penalties (including suspension, loss penalty as determined by the state) on plans if the commrequest for exemption is provided under knowingly false 

Oregon Or. Rev. Stat. 

Group health insurers, health care service con-

“Chemical dependency” means the addictive relationship with 

Mental health and substance abuse coverage requirementities providing coverage for hospital or medical expen
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

§743-556 Effective 2001 Amended 2007 

tractors, and HMOs providing coverage for hospital or medical expenses. 

any drug or alcohol characterized by either a physical or psychological relationship, or both, that interferes with the individual’s social, psychological or physical adjustment to common problems. The term does not include addiction to, or dependency on tobacco, tobacco products, or foods. “Mental or nervous conditions”are not defined. 

age for expenses arising from treatment for chemical dep

holism and mental or nervous conditions. Scope of coverage: Permits coverage to be subject to prbenefits under the policy, including but not limited to prtibles and coinsurance. • Prohibits deductible and coinsurance for treatment i

residential programs or facilities from being greater for expenses of hospitalization in the treatment of o

• Prohibits deductibles and coinsurance for outpatient 

greater than those under the policy for expenses of oer medical conditions. 

• Prohibits deductibles and coinsurance for treatment 

dential programs or facilities, or outpatient treatmenthose under the policy for expenses of such coveragillness. 

• Permits benefits to be provided by: 

 programs or providers approved by the office o

Programs or by the Mental Health and DevelopDivision; programs accredited for such care by creditation of Hospitals; and 

 licensed inpatient programs, residential, outpati

talization programs. 

• Prohibits payments for chemical dependency togeth

or nervous condition from being less than $13,125 fchildren. 

• Prohibits payments of less than less than $8,125 for 

children when requesting treatment for chemical dekind of mental or nervous condition. 

• Prohibits coverage from being subject to treatment l

payments for treatment, limits on duration of treatmments unless similar limitations or requirements are other medical conditions. 

• Permits an insured to receive covered outpatient ser

insured's policy while the insured is living temporaruation. 

• Permits, if specified in the policy, outpatient covera

home service or outpatient services.  Permits the policy to limit coverage for in-hom
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

are homebound under the care of a physician. 

• Does not require coverage for: 

 educational or correctional services or sheltered 

school or halfway house; 

 a long-term residential mental health program t

days; 

 psychoanalysis or psychotherapy received as pa

training program, regardless of diagnosis or sympresent; 

 a court-ordered sex offender treatment program a screening interview or treatment program. 

Benefit management: Permits coverage of eligible expetreatment that is medically necessary as determined undeical conditions.• Does not require affected entities to contract with al• Permits HMOs to limit the receipt of covered servic

provided by or upon referral by providers contractin

• Permits a group health insurer to manage of benefits 

thods, including but not limited to selectively contrabenefit differential designs, preadmission screeningvices, utilization review or other mechanisms designpenses to those outlined. 

• Subject to the patient or client confidentiality provis

practitioners, psychologists, and licensed clinical sofected entities to provide for review for level of treacontinued stays for treatment in health care facilitiefacilities, day or partial hospitalization programs anther group health insurer staff or personnel under coinsurer, or by a utilization review contractor, who mcertify for or deny level of payment. 

• Permits review to involve prior approval, concurren

tion of treatment, post-treatment review or any comif prior approval is required, requires provisions to bment of urgent or emergency admissions, subject to  If prior approval is not required, requires affect

viders, policyholders or persons acting on their inquiries regarding the appropriateness of a partreatment program. Requires affected entities t
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

to such inquiries. 

Out-of-network services: Requires affected entities to pcovered charges of non-contracting providers for the treadency or mental or nervous conditions. • Gives the insured the right to use the services of a n

the treatment of chemical dependency or mental or er or not the services for chemical dependency or mare provided by contracting or non-contracting prov

Pennsylvania Pa. Cons. Stat. §40.908-1, et. seq. Effective 1989 

Health insurers, hospital plan corporations, professional health services plan corporations, and HMOs issuing group health or sickness and accident insurance policies. Does not apply to Medicare or Medicaid supplemental contracts or limited coverage accident and sickness policies. 

“Alcohol and drug abuse” means any use of alcohol or other drugs which produces a pattern of pathological use causing impairment in social or occupational functioning or which produces physiological dependency evidenced by physical tolerance or withdrawal. 

Substance abuse coverage requirements: Requires afftreatment for alcoholism and drug addiction. Scope of coverage: Requires coverage for: • 7 days of inpatient detoxification services annually, 

• 30 outpatient visits annually, with 120 days per lifet

• 30 partial/residential days annually, with 90 days pe

• a course of treatment under a prospective payment p

same deductible or co-payment as applied to similar treatment for physical illness. 

Pennsylvania Pa. Cons. Stat. §40.6-764 Effective 1999 

Group health policies issued to groups of 50 or more employees. Does not include the following policies: accident only; fixed indemnity; limited benefit; credit; dental; vision; specified disease; Medicare supplement; 

“Serious mental illness” means any of the following mental illnesses as defined in the most recent DSM: • schizophrenia; • bipolar disorder; • obsessive-compulsive disorder; • major depressive disorder; • panic disorder; • anorexia nervosa; 

Mental health coverage requirements: Requires affecterage for serious mental illnesses. Scope of coverage: Requires coverage to: • provide at least 30 inpatient days and 60 outpatient 

be converted on a one for two basis for inpatient/ou

• have no differences between annual or lifetime doll

serious mental illness and any other illnesses; and 

• not prohibit access to care by imposing cost sharing 

but not limited to, deductibles and co-pays for covernesses. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

CHAMPUS supplement; long-term care; or disability income. 

• bulimia nervosa; • schizoaffective disorder; and • delusional disorder. 

Cost report: Requires the Legislative Budget and Financost and benefits of the requirements and make a report every two years. 

Rhode Island R.I. Gen. Laws §7-38-1 Effective 1989 

Health insurers. “Substance dependency and 

abuse” means the pattern of pathological use of alcohol or other psychoactive drugs characterized by impairments in social and/or occupational functioning, debilitating physical condition, inability to abstain from or reduce consumption for the substance, or the need for daily substance use for adequate functioning. 

Substance abuse coverage requirements: Requires insfor services relating to medically necessary treatment for and abuse. Scope of coverage: Requires coverage to include: • 30 hours of outpatient treatment annually furnished 

• 3 detoxification occurrences or 21 days annually (w

• 30 days of intensive rehabilitation services annually 

patient of 90 days for intensive rehabilitation. 

Rhode Island R.I. Gen. Laws §27-38.2-1, et. seq.Effective 1995 

Health insurers. Does not apply to hospital confinement indemnity, disability income, accident only, long-term care, Medicare supplement, limited benefit health, specific disease indemnity, sickness or bodily injury or death by accident or both, or other limited benefit policies, or government programs. 

“Mental illness” means any mental disorder and substance abuse disorder that is listed in the most recent edition of the DSM or ICD and that substantially limits the life activities of the person with the illness. • The term does not include 

tobacco and caffeine in the definition of “substance.” 

• The term does not include 

mental retardation, learning disorders, motor skills disorders, communication disorders, and mental disorders classified as “V” codes. 

Mental health and substance abuse parity requireme

ties to provide coverage for the medical treatment of sersubstance abuse under the same terms and conditions as er illnesses and diseases. Scope of coverage: Requires coverage to include the samlimits, deductibles, and coinsurance for serious mental iland diseases. • Requires the following minimum requirements: 

 outpatient services, with the exception of outpa

up to 30 visits in any calendar year; 

 outpatient services for substance abuse treatme

calendar year; 

 community residential care services for substan

to 30 days in any calendar year; and 

 detoxification benefits for up to 5 detoxification 

any calendar year, whichever comes first. 

• Requires mental health benefits to be delivered in th

tablished through a pre-authorization process that thavailable in the state from a provider in the insurer’
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Benefit management: Requires, upon request of the reiproviders of treatment of mental illness to furnish medicsary data which substantiates that initial or continued trecally necessary and appropriate. • Provides that a health insurer or patient is not obliga

when providers cannot establish the medical necessof the treatment being provided. 

• Requires health insurers to make medical necessity 

minations in a manner consistent with that used to mother treatments of other diseases or injuries. 

South Carolina S.C. Code. Ann. §38-71-737 Effective 1994 

Group health insurers. “Psychiatric conditions” means 

those mental and nervous conditions, drug and substance addition or abuse, alcoholism, or other conditions that are defined, described, or classified as psychiatric disorders or conditions in the most current publication of the DSM. 

Mental health mandated offer requirements: Requirean optional rider or endorsement for minimum psychiatrScope of coverage: Imposes minimum benefits of at lealifetime maximum benefit of $10,000. • Permits coverage to contain provisions prescribing d

chiatric conditions and physical conditions with respamount, coinsurance provision, or contract term affetions based upon use or nonuse of preferred provide

South Carolina S.C. Code Ann. §38-71-880 Effective 1997

Group health plans providing medical/surgical and mental health benefits. Does not apply to small employers with 1-50 employees. 

“Mental health benefits” means 

those as defined under the terms of the plan, but does not include benefits with respect to treatment of substance abuse. 

Mental health parity requirements: Prohibits affected ferent aggregate lifetime and annual dollar limits, numbe

ing, and medical necessity requirements on mental healtthose for medical/surgical benefits. 

South Carolina S.C. Code Ann. §1-11-760 Effective 2002 

State health insurance plan. 

“Mental health condition” means the following mental or nervous conditions that are caused by a biological disorder of the brain and results in a clinically signifiMental health and substance abuse coverage requirem

health insurance plan to provide coverage for the medicaa mental health condition and alcohol or substance abuseScope of coverage: Prohibits the establishment of any te
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Amended 2005 cant or psychological syndrome 

or pattern that substantially limits the functioning of the person with that illness: • schizophrenia; • schizoaffective disorder; • major depressive disorder; • bipolar disorder; • pervasive developmental disorder or autism; • panic disorder; • obsessive-compulsive disorder; • social anxiety disorder; • anorexia and bulimia; • Asperger’s disorder; • intermittent explosive disorder; • post-traumatic stress disorder; • psychosis not otherwise specified when diagnosed in a 

child under 17 years old; 

• Rett’s disorder; or • Tourette’s disorder. “Alcohol and substance abuse” means any condition or disorder involving alcohol or substance abuse that falls under any of the categories listed in the DSM. 

place a greater financial burden on an insured for access health condition or alcohol or substance abuse than for aphysical health condition. • Requires any deductible or out-of-pocket limits to b

erage of all conditions. 

Benefit management: If the state health insurance plan 

for management of care or does not provide the same dehealth conditions, it may provide management for medicmental health and alcohol or substance abuse as long as 

diminish or negate the above requirements. • Requires care management to ensure that: 

 timely and appropriate access to care is availab

 the quantity, location, and specialty distribution 

adequate; and 

 administrative or clinical protocols do not reduc

cessary treatment. 

South Carolina S.C. Code Ann. §38-71-290 Effective 2006 

Health insurance plans, defined as a health insurance policy or health benefit plan offered by a health insurer or an 

“Mental health condition” means 

the following psychiatric illnesses as defined in the DSM: • bipolar disorder; • major depressive disorder; 

Mental health parity requirements: Requires affected age for treatment of a mental health condition. • Prohibits the imposition of any rate, term, or conditi

nancial burden on an insured for access to treatment tion than for access to treatment for a physical healt
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 72 

State law Applicability Definitions Major provisions 

HMO, including a qualified health benefit plan offered or administered by the State, or a subdivision or instrumentality of the State, that provides health insurance coverage. 

• obsessive compulsive disorder; • paranoid or other psychotic 

disorder; 

• schizoaffective disorder; • schizophrenia; • anxiety disorder; • post-traumatic stress disorder; and • depression in childhood and 

adolescence. 

tings and treatment modalities. 

Scope of coverage: Requires any deductible or out-of-pa health insurance plan to be comprehensive for coveragphysical health conditions. • Requires treatment of mental illness to be rendered 

licensed mental health professional, or certified menmental health facility that provides a program for thhealth condition pursuant to a written treatment plan

Benefit management: Permits affected entities that do nmanagement of care under the plan, or that do not providmanagement of care for all health conditions, to provide mental health conditions through a managed care organiin compliance with state regulations. 

South Dakota S.D. Codified §58-18-80 Effective 1999 

Group health insurers. Does not apply to coverage limited to a specified disease or covered benefit. 

“Biologically based mental illness” means: • schizophrenia and other psychotic disorders; • bipolar disorder; • major depression; and • obsessive-compulsive disorder. 

Mental health parity requirements: Requires affected age for the treatment and diagnosis of biologically based same dollar limits, deductibles, coinsurance factors, and ered illnesses. 

South Dakota S.D. Codified §58-18-7.1 Effective 1979 

Group and blanket health insurers. 

No definitions. Substance abuse mandated offer requirements: Requ

fer coverage for the inpatient treatment of alcoholism in idential primary treatment facilities approved in South Dout an approved program pursuant to diagnosis and recoScope of coverage: Requires coverage to include: • 30 days of inpatient, outpatient, and partial/resident

to 90 days in a lifetime; and 

• the same co-pays, coinsurance, and lifetime dollar li

Tennessee Group health plans is- “Aggregate lifetime limit” means Mental health coverage requirements: Requires affect
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Tenn. Code Ann. §56-7-2360 Effective 2000 

sued by entities regulated under the state insurance code. Does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care or other limited benefit hospital insurance policies. Does not apply to small employers with 2-25 employees. Does not apply to individual policies. 

a dollar limitation on the total amount that may be paid for benefits under a health plan with respect to an individual or other coverage unit. “Annual limit” means a dollar limitation on the total amount that may be paid for benefits in a 12-month period under a health plan with respect to an individual or other coverage unit. “Medication management” means pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy. 

erage for mental health services as outlined below. Scope of coverage: If a group health plan provides both and mental health benefits, allows the plan to impose agannual limits as follows: 

 if the plan places no limit on substantially all m

plan may place no limit on mental health benef

 if the plan places limit on substantially all medi

plan may include mental health benefits under tlimit no less than the one applied to medical/ su

 if the plan contains varying limits on different m

the plan may apply an average limit to mental h

• Requires annual visit limits equal to or greater than 

and 25 outpatient or doctor visits (prohibits countinmanagement as an outpatient visit). 

• Allows substitution of less costly residential treatme

or crisis respite care at the rate of 2 alternate care dahospital treatment. 

• Prohibits an affected entity from counting an outpat

ment visit as an outpatient visit for purposes of detethe annual visit limit (noted above). 

• Allows a separate limit for mental health services fo

ing that is higher than a limit applied to medical/sur

• Prohibits the denial of coverage for services provide

pital owned or operated by this state that is especialdiagnosis, care and treatment of psychiatric, mental 

Benefit management: Allows the use of managed care benefits. Exemption for cost increases: Gives the commissioner exemption if an affected entity submits documentation thmandate results in an increase in cost of more than 1%. Rule of construction: Provides that the provisions shouthe amounts and terms of coinsurance, co-pays, deductibquired to be paid by the enrollee. • Clarifies that the mandate to provide coverage for m

same rates and terms as coverage provided for all m
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

does not apply to services for the abuse of or depend

Tennessee Tenn. Code Ann. §56-7-2601 Effective 1974 Amended 2000

Individual, franchise, blanket or group policies, group hospital or major medical policies, nonprofit hospital and medical service plan corporations. 

“Mental or nervous conditions” means conditions as defined in the DSM. The term does not include benefits for the treatment of substance abuse or chemical dependency. “Annual limit” means a dollar limitation on the total amount that may be paid for benefits in a 12-month period under a health plan with respect to an individual or other coverage unit. 

Mental health coverage requirements: Except for grouwhich §56-7-2360 applies (see above), requires affected hospital expense and surgical expense insurance to eithe

 provide benefits for expenses arising from psyc

nervous conditions, or the medical complication tal retardation; or 

 specifically exclude or reduce the above benefit

• Requires affected entities which propose to issue gr

cal, or medical policies or contracts to make availabexpenses at a community mental health center for themotional or nervous disorders, alcoholism, drug decomplication of mental illness or mental retardationtract is rejected in writing by the policy or contract 

• Subject to §56-7-2360 (see above), allows a group h

medical and surgical benefits and mental health benlifetime limits or annual limits as follows:  if the plan places no limit on substantially all m

the plan may place no limit on mental health be

 if a group health plan places limit on substantia

benefits, the plan may include mental health beapply a separate limit no less than the one applibenefits; or 

 if the plan contains varying limits on different m

fits, the plan may apply an average limit to men

• Clarifies that the above provisions on aggregate and 

quire a group health plan to provide mental health b

• Exempts from the provisions on aggregate and annu

 group health plans issued to small employers of 

 group health plans with an increase of cost of a

plication of the provision. 

Scope of coverage: Requires the coverage to be made adered at a community mental health center to include: • the same deductibles and coinsurance as physical ill

• a minimum of 30 outpatient visits annually. 
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State law Applicability Definitions Major provisions 

Tennessee Tenn. Code Ann. §56-7-2602 Effective 1982 

Group health insurers, non-profit hospitals and medical service plan corporations, and HMOs. Does not apply to blanket, short term travel, accident only, limited or specified disease, individual conversion policies, or federal or state programs. 

No definitions. Substance abuse mandated offer requirements: Requ

viding hospital and medical coverage to offer and make necessary care and treatment of alcohol and other drug dfavorable than for physical illnesses generally, subject to its, dollar limits, deductibles and coinsurance factors. • Allows group policyholders to reject the offered cov

TennesseeTenn. Code Ann. §56-6-705Effective 2007 

Utilization review agents. 

No definitions. Mental health and substance abuse coverage requirem

entities to approve at least 12 visits to a particular providhealth and chemical dependency care for a patient once pursuant to policy or contract requirements. • Requires affected entities to provide 12 additional v

ommended after a utilization review. 

Texas Tex Code Ann. Ins. §1355.001, et. seq. Effective 1991 Amended 2003 Tex Code Ann. Ins. §1355.051, et. seq. Effective 1987 Amended 2003 Tex Code Ann. Ins. §§1355.104 

Group health benefit plans. Does not apply to blanket accident policies, short-term travel policies, accident-only policies, limited or specified-disease policies, and Medicare supplement policies. 

“Serious mental illness” means the following psychiatric illnesses as defined by the DSM: • schizophrenia; • paranoia and other psychotic 

disorders; 

• bipolar disorders; • major depressive disorders 

(single episode or recurrent); 

• schizoaffective disorders (bipolar or depressive); • pervasive developmental disorders; • obsessive compulsive disorders; and 

Mental health coverage requirements: Requires affectemployers (defined as employers with 50 employees or lage outlined below. • Requires affected entities to offer the coverage outli

ployers. 

• Requires affected entities to offer coverage for “alte

for treatment of mental or emotional illnesses or dishospital or a psychiatric day treatment facility. 

Scope of coverage: Requires coverage of medically necinpatient and 60 visits for outpatient, including group antreatment. • Prohibits the inclusion of lifetime limits on the num

outpatient visits covered. 

• Requires the imposition of the same amount limits, 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

through1355.106 Effective 1983 Amended 2003 

• depression in childhood and 

adolescence. 

Hospital confinement provisions stipulate that coverage may be used only in a situation in which the individual has a serious mental illness that requires confinement of the individual in a hospital unless treatment is available through a residential treatment center for children and adolescents or a crisis stabilization unit; and the individual’s mental illness: • substantially impairs the individual’s thought, perception of reality, emotional 

process, or judgment; or 

• as manifested by the individual’s recent disturbed behavior, grossly impairs the individual’s behavior. 

coinsurance factors for serious mental illness as for 

• Requires affected entities providing coverage for th

emotional illnesses or disorders when the individual also provide coverage for treatment in a residential ren and adolescents or a crisis stabilization unit that the coverage the plan provides for treatment of mendisorder in a hospital.  Requires hospital confinement coverage to be b

treatment plan for the covered individual and p

vider licensed or operated by the appropriate stservices. 

 Requires hospital confinement benefits to be su

maximums, durational limitations, deductibles, that apply to inpatient psychiatric treatment. 

 Requires treatment in a residential treatment ce

lescents or crisis stabilization unit to be determand treatment were inpatient care and treatment 

 Requires 2 days of treatment in a residential tre

and adolescents or crisis stabilization unit to be treatment of mental or emotional illness or disotient program. 

• Requires group insurance policies providing covera

mental or emotional illness or disorder when an indhospital to also provide coverage for treatment obtaand continued medical supervision of a doctor in a pfacility that provides organizational structure and inplans separate from an inpatient program.  Requires benefits provided to be determined as 

treatment in a psychiatric day treatment facility 

a hospital. 

 Requires, with respect to determining policy be

imums, that one full day of treatment in a psychty to be equivalent to 1⁄2 of 1 day of treatment oness or disorder in a hospital or inpatient progra

 Prohibits psychiatric day treatment facility cove

vorable than the hospital coverage, and requires same durational limits, deductibles, and coinsurcoverage. 

 Permits treatment obtained in a psychiatric day 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 77 

State law Applicability Definitions Major provisions 

provided by a facility that treats a patient for no24 hour period. 

 Permits the requirement that attending physicia

a psychiatric day treatment facility is in lieu of 

 Permits the requirement that psychiatric day tre

credited by the Joint Commission on Accredita

• Requires alternative level of benefits to provide poli

maximums for treatment in a psychiatric day treatmleast half of that provided for treatment in a hospitaltreatment in a psychiatric day treatment facility may customary rate of the facility. 

Benefit management: Permits coverage to be provided naged care plan. 

Texas Tex. Code Ann. Ins §1551.205 Effective 2001 Tex. Code Ann. Ins. §1355.151 Effective 2003 

State government employees and political subdivisions of local governments providing group health insurance, HMO, or self-insured health coverage. 

 "Serious mental illness" means the following psychiatric illnesses as defined in the DSM: • bipolar disorders (hypomanic, manic, depressive, and 

mixed); 

• depression in childhood and 

adolescence; 

• major depressive disorders 

(single episode or recurrent); 

• obsessive-compulsive disorders; • paranoid and other psychotic 

disorders; 

• pervasive developmental disorders; • schizo-affective disorders 

(bipolar or depressive); and 

• schizophrenia. 

Mental health parity requirements: Prohibits the state of local governments from providing or contracting for cillness that is less extensive than coverage for any physic

Utah Utah Code Ann. 

Group accident and health insurance. 

No definitions. Substance abuse mandated offer requirement: Requi

tain an optional rider allowing certificate holders to obta
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

§31A-22-715 Effective 1986 Amended 2001 

drug dependency treatment in programs licensed by the vices, inpatient hospitals accredited by the Joint Commiof Hospitals, or facilities licensed by the Department of 

Utah Utah Code Ann. §31A-22-625 Effective 2000 Amended 2008 

Insurers. “Catastrophic mental health coverage” means coverage in a 

health benefit plan or HMO contract that does not impose a lifetime limit, annual payment limit, episodic limit, inpatient or outpatient service limit, or maximum out-of-pocket limit that places a greater financial burden on an insured for the evaluation and treatment of a mental health condition than for the evaluation and treatment of a physical health condition. • The term may include a restriction on cost sharing factors, such as deductibles, copays, or coinsurance, prior to 

reaching any maximum outof-pocket limit. 

• It may include 1 maximum 

out-of- pocket limit for physical health conditions and another maximum out-ofpocket limit for mental health conditions, provided that, if separate out-of-pocket limits are established, the out-ofpocket limit for mental health conditions may not exceed the out-of-pocket limit for physical health conditions. 

Mental health coverage requirements: Requires an insmental health coverage as part of an HMO contract or he• Does not apply to individual policies or contracts.Mental health mandated offer requirements for smalinsurer to offer small employers (defined as 2 – 50 emplchase and renewal, a choice between catastrophic mentamental health coverage. • Allows an insurer to offer catastrophic mental health 

health coverage, or both at levels that exceed the mithis section; or coverage that excludes benefits for m

• Permits a small employer, at its option, to choose ei

health coverage, 50/50 mental health coverage, or othe insurer, regardless of the employer's previous coconditions. 

• Provides an exemption from the 30% index rating re

state law for the first year only that catastrophic mensen, the 15% annual adjustment restriction under staployer with 20 or less enrolled employees who chooexceeds catastrophic mental health coverage. 

Mental health mandated offer requirements for large surers, at the time of purchase and renewal, to offer cataerage to each large employer (defined as 51 or more emp• Allows an insurer to offer to provide catastrophic m

levels that exceed the minimum requirements of thi

• Permits a large employer, at its option, to choose eit

health coverage, coverage that excludes benefits for or other coverage offered by the insurer. 

Benefit management: Allows an insurer to provide catacoverage through a managed care organization or system with state law, regardless of whether the policy or contra
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 79 

State law Applicability Definitions Major provisions 

“50/50 mental health coverage”means coverage in a health benefit plan or HMO contract that pays for at least 50% of covered services for the diagnosis and treatment of mental health conditions. • The phrase may include a restriction on episodic limits, 

inpatient or outpatient service limits, or maximum out-ofpocket limits. 

 “Mental health condition” means any condition or disorder involving mental illness that falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual, as periodically revised. • It does not include the following when diagnosed as 

the primary or substantial reason or need for treatment: (a) marital or family problem; (b) social, occupational, religious, or other social maladjustment; (c) conduct disorder; (d) chronic adjustment disorder; (e) psychosexual disorder; (f) chronic organic brain syndrome; (g) personality disorder; (h) specific developmental disorder or learning disability; or (i) mental retardation. 

ganization or system for the treatment of physical health • Permits insurers to establish a closed panel of provi

health coverage. 

• Allows insurers to refuse to provide any benefit to b

dered by a non-panel provider unless: 

 the insured is referred to a non-panel provider w

of the insurer; and 

 the non-panel provider agrees to follow the insu

ment guidelines. 

• Provides that to be eligible for catastrophic mental h

or treatment of a mental health condition must be retherapist or in a health care facility licensed or othermental health services that provides a program for thealth condition pursuant to a written plan. 

Out-of-network services: Provides that nothing may be 

insurer to authorize a referral to a non-panel provider. 

Vermont Insurers and managed “Mental health condition” means Mental health and substance abuse parity requireme
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 80 

State law Applicability Definitions Major provisions 

Vt. Stat. Ann. §§4089b and 9414(g) Effective 1998 Amended 2008 

care organizations offering health insurance plans including those offered by the state. Requires a managed care organization providing or administering coverage on behalf of insurance plans to abide by the same rules as the insurer. Assigns a health insurer responsibility for the actions of a managed care organization it contracts with. 

any condition or disorder involving mental illness or alcohol or substance abuse that falls under any of the diagnostic categories listed in the mental disorders section of the ICD classification. 

ties to provide coverage for treatment of a mental health lish any rate, term or condition that places a greater burdto treatment for a mental health condition than for acceshealth conditions. Scope of coverage: Requires any deductible or out-of-phensive for coverage of both mental health and physical Benefit management: Allows affected entities to providproved managed care organization to the extent that the otherwise provide for management of care under the plamanagement for all health conditions. 

Vermont Vt. Code R. §80-1 Effective 1980 

All individual accident and sickness insurance policies and subscriber contracts of hospital, medical and dental service corporations except Medicare supplement policies or certificates, delivered or issued for delivery. Does not apply to individual policies or contracts issued pursuant to a conversion privilege under a policy or contract of group or individual insurance when such group or individu-

"Mental or nervous disorders"includes neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or disorder of any kind.

Mental health parity requirements: Prohibits an affeccontract from containing a definition for “mental or nervrestrictive a definition than one including neurosis, psycpsychosis, or mental or emotional disease or disorder of • Prohibits policies from limiting or excluding covera

dent, treatment or medical condition except, among emotional disorders, alcoholism, and drug addiction
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

al policy or contract includes provisions which are inconsistent with the requirements of this regulation. 

Virginia Va. Code Ann. §38.2-3412.1 Effective 2004 

Insurers offering individual and group accident and sickness policies. Does not apply to shortterm travel, accidentonly or specified disease policies, shortterm nonrenewable policies, Medicare or federal or state government plans. 

No definitions. Mental health and substance abuse coverage requirem

entities to provide coverage for inpatient and partial hospand substance abuse services that are no less restrictive t(except as outlined below). Scope of coverage: Requires coverage for: • 20 days of inpatient treatment for adults and 25 day

children per policy or contract year; 

• up to 10 days of inpatient care which can be conver

of partial/residential treatment for 1 day of inpatient 

• 20 days of outpatient treatment for adults and childr

year; 

• coinsurance for outpatient visits beyond the first 5 v

or contact year shall be at least 50% percent; and 

• outpatient visits subject to a deductible (does not co

benefit maximum). 

Virginia Va. Code Ann. §38.2-3412.1:01 Effective 2000 Amended 2004

Insurers, corporations, and HMOs issuing or providing group policies. Does not apply to shortterm travel, accidentonly or specified disease policies, shortterm nonrenewable policies, Medicare or federal or state government plans. 

“Biologically based mental illness” means any mental or nervous condition caused by a biological disorder of the brain that result in a clinically significant syndrome that substantially limits the person’s functioning. The definition includes: • schizophrenia; • schizo-affective disorder; • bipolar disorder; • obsessive-compulsive disorder; • major depressive disorder; 

Mental health and substance abuse coverage requireentities to provide coverage for biologically based mentaScope of coverage: Permits benefits for biologically basferent from benefits for other illnesses, conditions, or dismeet the medical criteria necessary to achieve the same by the benefits for any other covered illness, condition o• Prohibits terms of mental health coverage from bein

from coverage for any other illness, condition or dis

 deductibles, benefit year, or lifetime durational 

 benefit year or lifetime dollar limits; 

 lifetime episodes or treatment limits; 

 co-pay or coinsurance factors; and  benefit year maximums for deductibles, co-pay 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

Does not apply to individual policies or policies issued to employers with 25 or fewer employees. 

• panic disorder; • attention deficit disorder; • autism; and • drug and alcohol addiction. 

Benefit management: Does not preclude insurers from ty determinations on mental health benefits as long as thtions are the same as those used for other illnesses, condunder the contract. 

Washington Wash. Rev. Code §§48.21.180 and 48.44.240 Effective 1990 

Group disability insurers4 and group contracts 

for health care services. 

No definitions. Substance abuse coverage requirements: Requires af

benefits for the treatment of chemical dependency rendement facility or program. Scope of coverage: Requires coverage to provide paymfor any medically necessary treatment and supporting se

proved treatment program with a minimum benefit of $1period. • Allows coverage to be limited by provisions of the p

other benefits. 

• Allows a 3 month pre-existing limitation if the limit

chronic illnesses. 

Benefit management: Permits limiting coverage to specthe carrier provides or contracts for the provision of app• Except for detoxification services, allows a requirem

and second opinions, if the second opinion is requirnesses. 

• Permits a carrier to make an independent evaluation 

to scheduled treatment in situations where the assescourt order or related to certain legal proceedings. 

Washington Wash. Rev. Code §48.21.240 Effective 1987 Amended 2005 

Group disability insurers, including insurers, health care service contractors, and HMOs. 

No definitions. Mental health mandated offer requirements: Require

optional supplemental coverage for mental health treatmScope of coverage: Permits treatment to be subject to “ramounts or co-pays. • Requires coverage to be provided by a state licensed 

4 In Washington, health insurance is known as “disability insurance.” For more information, see AHIP’s Disability Income Protection a

 Definitions chart. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

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State law Applicability Definitions Major provisions 

community mental health agency, or state hospital. 

• Requires coverage to be provided at the usual and c

treatment; however, allows affected entities to estabtomary rates for services rendered by the above-stat

Washington Wash. Rev. Code §§41.05; 48.21; 48.44; 48.46; and 70.47 Effective 2005 Amended 2006 

Public employees program; Washington Basic Health Plan; and group disability insurers, health care service contractors, and HMOs providing medical and surgical benefits to groups with 50 or more employees. 

“Mental health services" means medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the DSM, with the exception of: • substance related disorders; • life transition problems, currently referred to as "V" 

codes, and diagnostic codes 302 through 302.9 as found in the DSM; 

• skilled nursing facility services, home health care, residential treatment, and custodial care; and • court ordered treatment unless the authority's or contracted insuring entity's medical director determines the 

treatment to be medically necessary. 

Mental health coverage requirements: Requires affecterage for mental health services. Scope of coverage: Prohibits co-pays or coinsurance for 

from being more than the co-pays or coinsurance for mecept for wellness and preventive services provided or reicoinsurance, or other cost sharing than other medical/sur• Requires prescription drugs intended to treat any of 

covered to the same extent, and under the same termcovered prescription drugs. 

• For health benefit plans established or renewed on o

also requires that any maximum out-of-pocket limit limit or stop-loss for medical, surgical, and mental h

• For health benefit plans established or renewed on o

requires mental health services to be included with mvices for the purpose of meeting the deductible requpermits treatment limitations on or any other financage for mental health services if the same limitationposed on coverage for medical and surgical services

• Prohibits affected entities from reducing the numbe

tient visits or inpatient days below the level in effec

Benefit management: Permits the application of medicby the medical director or designee, if a comparable requmedical and surgical services. • Permits the management of mental health services. 

• Requires the administrator to consider care managem

health services, including but not limited to:  authorized treatment plans; 

 preauthorization requirements based on the typ

 concurrent and retrospective utilization review;  utilization management practices; 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 84 

State law Applicability Definitions Major provisions 

 discharge coordination and planning; and  contracting with and using a network of particip

WashingtonWas. Rev. Code §§48.20.580; 48.21.241; 48.44.341; and 48.46.291Effective 2008

Group insurance (except for small groups) provided by disability insurers; health service contracts providing health benefit plans; and HMOs; and the state’s high risk pool 

"Mental health services" means medically necessary outpatient and inpatient services provided to treat mental disorders covered by the diagnostic categories listed in the most current version of the DSM with the exception of the following categories, codes, and services: a) substance related disorders; 

b) life transition problems, currently referred to as "V" 

codes, and diagnostic codes 302 through 302.9; 

c) skilled nursing facility services, home health care, residential treatment, and custodial care; and 

d) court-ordered treatment unless the insurer's medical director or designee determines 

the treatment to be medically necessary. 

Mental health parity requirements: Prohibits co-pays health services from being more than those for medical aerwise provided under the contract. • Requires contracts imposing a maximum out-of-poc

impose a single limit or stop-loss for medical, surgicvices. 

• Requires prescription drugs for mental illnesses to b

tent and under the same terms and conditions as othdrugs. 

Scope of coverage: Requires contracts imposing a maxistop loss, to impose a single limit or stop-loss for medicahealth services. • Requires prescription drugs for mental illnesses to b

tent and under the same terms and conditions as othdrugs. 

• Prohibits the reduction of the number of mental hea

tient days below the level in effect on 07/01/02. 

• Requires the policy issued by the state’s high-risk p

cessary eligible services including mental health car

• Requires the state’s high-risk pool to cover the first 

dered at a state-certified chemical dependency progcians, psychologists, or community mental health prtion of a physician, by other qualified licensed healtble for coverage. 

Benefit management: Allows for the application of methe medical director or designee, if a comparable requireical/surgical services. 

West Virginia W. Va. Code §33-16-3c 

Group, blanket, franchise or association accident and sickness insurance. “Alcoholism” means a chronic disorder or illness in which the individual is unable, for psycho- logical or physical reasons, or Substance abuse mandated offer requirements: Requ

the option of the policyholder or sponsor, provide the levalcoholism. 
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 85 

State law Applicability Definitions Major provisions 

Effective 1998 both, to refrain from the frequent 

consumption of alcohol in quantities sufficient to produce intoxication and ultimately, injury to health and effective functioning. 

Scope of coverage: Requires: • a minimum of 30 days of inpatient treatment (if inp

provided beyond 20 days, the durational limits, dollcoinsurance need not be the same as for physical illn

• maximum coinsurance for outpatient benefits of 50% 

physical illnesses; 

• minimum benefit in any benefit period of at least $7

• maximum lifetime benefits of at least $10,000 or 25

West Virginia W. Va. Code §33-16-3a Effective 1998 Amended 2007 

Health benefit plans, insurers, and HMOs offering group and individual coverage. 

“Serious mental illness” means an illness included in the DSM under the diagnostic categories or sub-classifications of: • schizophrenia and other psychotic disorders; • bipolar disorders; • depressive disorders; • substance-related disorders 

with the exception of caffeine and nicotine--related disorders; 

• anxiety disorders; and • anorexia and bulimia. Does not include custodial care, residential care, or schooling. 

Mental health coverage requirements: Requires affectfits for expenses arising from treatment of serious menta• Prohibits discrimination between medical-surgical b

benefits in the administration of its plan. 

Scope of coverage: Requires aggregate lifetime and annfollows: 

 prohibits a plan from imposing any aggregate li

mental health benefits if the plan does not incluannual limit on substantially all medical/surgicader the terms of the plan, but not including men

 requires a plan that limits the total amount that 

coverage for substantially all medical/surgical bapplicable lifetime or annual limit to medical/suwould otherwise apply and to mental health benterms of the plan) without distinguishing betweing any aggregate lifetime or annual limit on mless than the applicable lifetime limit; 

• Permits the commissioner to impose rules for those 

scribed above with respect to prohibiting different alimits on different categories of medical/surgical ben

Benefit management: Permits insurers to use recognizecost management tools, including, but not limited to: 

 utilization review; 

 provider networks; 

 cost containment measures; 

 preauthorization; 

 coverage levels including the number of visits i
Mental Health and Substance Abuse Coverage and Parity: Summary of Federal and State Requir

© America’s Health Insurance Plans. All rights reserved 86 

State law Applicability Definitions Major provisions 

 capitated benefit arrangements;  fee-for-service arrangements;  third-party administrators;  cost-sharing in the form of co-pays, deductibles

Exemption for cost increases: Permits insurers that can that its total anticipated costs for treatment for mental illwill exceed or have exceeded 2% of the total costs for superiod to apply whatever cost containment measures mabut not limited to, limitations on inpatient and outpatient at below two percent of total costs. 

• Allows insurers to apply additional cost containmen

cessary for any group with 25 members or fewer if costs for the treatment of mental illness will exceed the group. 
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© America’s Health Insurance Plans. All rights reserved 87 

State law Applicability Definitions Major provisions 

Wisconsin Wis. Stat. §632.89 Effective 2000 Amended 2006 

Group or blanket disability insurers.5

Does not apply to limited health service organizations. 

No definitions. Does not include costs incurred for prescription drugs and diagnostic testing. 

Mental health coverage requirements: Requires affecterage of any inpatient hospital services to cover inpatienof nervous and mental disorders and alcoholism and othprovided below. Scope of coverage: Mandates coverage in an amount eq

 the expenses of 30 days of inpatient services; o $7,000 minus the applicable cost sharing under 

cost sharing under the policy, $6,300 in equivalservices rendered. 

• Requires affected entities providing coverage of any 

es to cover outpatient services for the treatment of ners and alcoholism and other drug abuse problems i $2,000 minus the applicable cost sharing under  if there is no cost sharing under the policy, $1,8

measured in services rendered. 

• Requires affected entities providing coverage of any 

hospital services to cover the cost of transitional trethe treatment of nervous and mental disorders and aabuse problems in the minimum amount of:  $3,000 minus the applicable cost sharing under  if there is no cost sharing under the policy, $2,7

measured in services rendered. 

• Provides that the required coverage amounts do not 

tion drugs and for diagnostic testing used to exclude tions other than nervous or mental disorders or alco

• Provides that coverage for both inpatient and outpat

all types of treatment for nervous and mental disordother drug abuse problems need not exceed $7,000/lent benefits measured in services rendered in a poli

• Requires affected entities paying less than the amou

to have minimum coverage limits apply to the amousurer rather than to the amount charged by the provi

5 In Wisconsin, health insurance is known as “disability insurance.” For more information, see AHIP’s Disability Income Protection an

 Definitions chart.