Q1: What mental illness/substance abuse benefits am I provided in the state of Maryland?
If your plan meets the definition of a “Health Benefit Plan” as defined by Code of Maryland §15–1301 or §15–1401 (click here for definitions), the plan will provide at least the following benefits for the diagnosis and treatment of a mental illness, emotional disorder, drug use disorder, or alcohol use disorder:
Inpatient benefits for services provided in a licensed or certified facility, including hospital inpatient and residential treatment center benefits
Partial hospitalization benefits
Outpatient and intensive outpatient benefits, including all office visits, diagnostic evaluations, opioid treatment services, medication evaluation and management and psychological and neuropsychological testing for diagnostic purposes
The benefits under this section are required only for expenses arising from the treatment of mental illnesses, emotional disorders, or drug or alcohol misuse if, in the professional judgment of health care providers the condition is treatable and that treatment is medically necessary.
The benefits required under this section:
Shall be provided as one set of benefits covering mental illnesses, emotional disorders, drug misuse and alcohol misuse
Shall comply with 45 C.F.R. § 146.136(a) through (d) and 29 C.F.R. § 2590.712(a) through (d)
May be delivered under a managed care system
May not be less than 60 days for partial hospitalization
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.
MHPAEA originally applied to group health plans and group health insurance coverage and was amended by the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively referred to as the "Affordable Care Act") to also apply to individual health insurance coverage.
You can find more information about this protection at: https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html
You may also contact the Maryland Insurance Administration about the benefits at:
200 St. Paul Place
Baltimore, MD 21202
410-468-2000 | 1-800-492-6116 (toll free) | 1-800-735-2258 (TTY)
If you have a precertification requirement, but fail to precertify, a penalty may be applied. Again, check your Schedule of Benefits or Certificate Schedule for the potential penalty.