Mental health parity: the plan must prove its limits are comparable
A plan that covers mental health or substance-use treatment may not apply prior authorization, step therapy, network rules or medical-necessity standards more stringently than it applies them to medical and surgical care, and it must produce a comparative analysis of those limits on request. Ask for the analysis; many denials cannot survive it.
When it applies
- Denials of residential treatment, intensive outpatient, ABA, psychotherapy frequency, medication-assisted treatment
- Employer plans (ERISA), marketplace and most individual plans
Where it does not
- Original Medicare (not subject to MHPAEA)
- Retiree-only and some small self-funded church plans
The sentence to put in the appeal
“Please provide, as 29 CFR 2590.712(c)(4) and the plan's disclosure obligations require, the comparative analysis demonstrating that the non-quantitative treatment limitation applied here [prior authorization / concurrent review / medical-necessity criteria] is comparable to and applied no more stringently than the corresponding limitation on medical/surgical benefits in the same classification, together with the medical-necessity criteria for both.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Name the limitation
Concurrent review every three days, a residential 'fail-first' rule, a network exclusion: identify the mechanism the plan used.
- Step 2
Ask for the medical/surgical comparison
The plan must show how the same kind of limit works on the medical side. Vague answers are themselves a finding.
- Step 3
Complain to the regulator in parallel
The Department of Labor and state insurance departments enforce parity and take complaints alongside your appeal.
Worked example
Residential treatment for an eating disorder was cut off after ten days under a plan guideline. The appeal requested the comparative analysis; the plan could not show an equivalent limit for medical rehabilitation stays and approved the remaining days.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
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Sources
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