Parity Violation Examples

Parity Violation Examples

Under state and federal mental health parity laws, health insurance companies/Plans are required to provide treatment for mental/behavioral disorders and substance abuse equitable (on “par”) to physical illnesses or injuries. Below are five common “parity” violations.

  • Excessive or different co-payment or co-insurance:
    • If your health plan charges you different co-payment or co-insurance for mental or behavioral health services than those charged for similar level of medical services, this is likely a federal parity law violation.
  • Withholding authorization, treatment or payment due to Fail-first policies:
    • If your health plan withholds authorization, denies care, or denies payment for mental or behavioral services because the member has not yet tried and failed at a lower level of care, this is likely a federal parity law violation.
  • Limiting the quantity or frequency of mental health treatment:
    • If your health plan limits the number of visits you have for mental health (i.e. yearly or lifetime visits) or how often you can visit your provider, particularly if different than your access for physical treatments, this is likely a federal parity law violation.

Certain type of parity violations are often best identified with the support and experience of your healthcare provider. You may want to ask your provider about the following parity violations:

  • Imposing more restrictive prior authorization (IR) policies for mental and/or behavioral health treatment:
    • If your health plan requires prior authorization for any level of service that is not required for a similar physical treatment or requires greater clinical detail (either for admit criteria or treatment planning)
  • Imposing excessive concurrent review (UR) policies for mental and/or behavioral health treatment:
    • If your health plan requires ongoing “medically necessity” reviews with your provider to justify your continued treatment, and this requirement is too frequent, overly burdensome, or does not conform to the plans stated guidelines, it is likely a violation of federal parity law.

More Parity Information: