Florida Behavioral Health Care Services Disclosure
Florida law, under 627.4215 F. S. requires health insurance carriers to inform you of federal and state requirements for coverage of Behavioral Health Care Services.
What is Behavioral Health?
Behavioral Health means the emotions and behaviors that affect a person’s overall mental well-being, their ability to function in everyday life, and their concept of self. Behavioral health encompasses all contributions to mental wellness including substance use, abuse, and recovery.
What is Mental Health Parity?
Mental health parity describes the equal treatment of mental health conditions and substance use disorders in insurance plans. When a plan has parity, it means that the plan will reimburse mental health or substance use disorders to the same extent as any other medical condition. In other words, a plan may not impose more restrictive financial requirements or treatment limitations to mental health or substance use, abuse, and recovery benefits than those on any other medical and/or surgical benefits.
Fidelity Security Life Insurance Company® (FSL) does not offer “group health plans” subject to Florida and federal Mental Health Parity laws. Nonetheless, FSL is mandated by Florida law to provide you with information to help you understand how Behavioral Health Care Services work under Florida and Federal law.
Questions or Complaints
If you need assistance with mental health or substance use disorder benefits, or have any other questions or concerns, you can contact the Florida Division of Consumer Services at:
Telephone: In-state: toll-free 1-877-MY-FL-CFO (1-877-693-5236). Out-of-State: (850) 413-3089.
Florida: Behavioral Health Benefits Available in Florida
Insurance coverage and benefits for behavioral health services can vary depending on the type of health insurance policy or contract a person is covered under, including if it is an individual, small group or large group health plan and when the policy was originally issued. Coverage requirements are dictated by state and/or federal law based on these and other factors.
Florida: Requirements for Coverage by Group Health Plans
Section 627.668, Florida Statutes, requires insurers of group health plans to make available to the policyholder (i.e. employer) as part of the application, for an appropriate additional premium, under a hospital and medical expense-incurred insurance policy, under a prepaid health care contract, and under a hospital and medical service plan contract, coverage for mental and nervous disorders. The application of the requirements of s. 627.668, F.S., depends on whether a group health plan is considered grandfathered, transitional, or non-grandfathered as well as if it is determined to be a small (1-50 employees) or a large (51+ employees) group.
Grandfathered and transitional small group plans have the option to include mental and nervous disorder benefits and, if they do, they must meet the requirements of this statute. Large group health plans have the option to provide mental and nervous disorder coverage and, if they do, they must comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA). The requirements of the MHPAEA are discussed in detail in the next section.
Grandfathered health plans are policies or contracts purchased prior to the passage of the Patient Protection and Affordable Care Act on March 23, 2010. Transitional policies are contracts purchased between March 24, 2010, and December 31, 2013. The employer or group health plan issuer can confirm if a health plan is grandfathered or transitional. If you are covered under a grandfathered or transitional small group health plan that provides mental and nervous disorder benefits, the health plan must provide for the necessary care and treatment of mental and nervous disorders, as defined in the standard nomenclature of the American Psychiatric Association. The inpatient hospital benefits, partial hospitalization benefits, and outpatient benefits—consisting of durational limits, dollar amounts, deductibles, and coinsurance factors—shall not be less favorable (parity) than for physical illness generally, with a few exceptions:
A. Inpatient benefits may be limited to no less than 30 days per benefit year as defined in the policy or contract. If inpatient hospital benefits are provided beyond 30 days per benefit year, parity requirements do not apply.
B. Outpatient benefits may be limited to $1,000 for consultations with a licensed physician, a psychologist licensed pursuant to Chapter 490, a mental health counselor licensed pursuant to Chapter 491, a marriage and family therapist licensed pursuant to Chapter 491, and a clinical social worker licensed pursuant to Chapter 491. If inpatient hospital benefits are provided beyond 30 days per benefit year, parity requirements do not apply.
C. Partial hospitalization benefits shall be provided under the direction of a licensed physician. In a given benefit year, if partial hospitalization services or a combination of inpatient and partial hospitalization are used, the total benefits paid for all such services may not exceed the cost of 30 days after inpatient hospitalization for psychiatric services, including physician fees, which prevail in the community in which the partial hospitalization services are provided. If inpatient hospital benefits are provided beyond 30 days per benefit year, parity requirements do not apply.
Please note that s. 627.668(2), F.S., does not apply to large group plans, self-insured plans under the Employee Retirement Income Security Act of 1974 (ERISA) or group health plans issued outside the State of Florida.
Federal Law: The Mental Health Parity & Addiction Equity Act (MHPAEA)
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law aimed at preventing coverage discrimination between policyholders or members who are seeking mental health or substance use disorder (MH/SUD) benefits and those seeking medical and surgical benefits. A lack of parity can prevent a person from pursuing needed care due to cost or limited access, or otherwise make it more expensive or more time intensive than medical visits.
The MHPAEA was passed by Congress in 2008 with the purpose of providing added protections to the Mental Health Parity Act (MHPA) that was passed in 1996. Combined, these federal laws require parity with medical and surgical benefits for annual and aggregate lifetime limits, financial requirements, treatment limitations, and in- and out-of-network coverage, if a plan provides coverage for mental health. Quantitative treatment limitations (QTL) refer to the financial limitations such as coverage limits or out-of-pocket expenses (copayment, deductible, or coinsurance, and out of pocket maximums). Example: If most copayments under a plan for medical or surgical office visits are not usually more than $30, the copayments for office visits to mental health professionals should be around the same amount.
Non-quantitative treatment limitations (NQTL) refer to non-numerical standards, such as medical-management standards, pre-authorization, formularies for prescriptions, and fail-first policies or step-therapy protocols. Standards for medical necessity determinations and reasons for any denial of benefits relating to MH/SUD must be disclosed by the insurer upon request.
The requirements of the MHPA and MHPAEA applied primarily to large group health plans until the passage and implementation of the Affordable Care Act (ACA). Small group and individual qualified health plans effective on or after January 1, 2014, are required to provide ten essential health benefits, with one of the benefits being coverage for mental health and substance use disorders. Federal guidelines require individual and small group plans subject to the ACA to meet the requirements of the MHPAEA to satisfy the essential health benefit mandate. Grandfathered and transitional individual and small group health plans are not required to include mental health and substance use disorder benefits and are not subject to requirements of the ACA as it relates to mental health benefits. However, if a grandfathered or transitional individual health plan includes mental health benefits, it must comply with the requirements of the MHPAEA.
Additional details about the requirements under the MHPAEA can be found on the Center for Medicare and Medicaid’s (CMS) website at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.
If you have additional questions regarding compliance with MHPAEA, you may contact the Department of Health and Human Services (HHS) by calling toll-free at 1-877-267-2323 extension 6-1565 or emailing firstname.lastname@example.org. You may also contact a benefit advisor in one of the Department of Labor’s regional offices at www.askebsa.dol.gov or by calling toll-free at 1-866-444-3272.