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Behavioral Health Care Services

WHAT IS BEHAVIORAL HEALTH?

The term “behavioral health” refers to the promotion of mental health, resilience and well-being; the treatment of mental health and substance use disorders; and the support of those who experience and/or are in recovery from these conditions, along with their families and communities.

Mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her own community.

Mental illness is collectively all diagnosable mental disorders or health conditions that are characterized by alterations in thinking, emotion, or behavior (or some combination thereof) associated with distress and/or problems functioning in social, work, or family activities. While mental health refers to an individual’s mental state of well-being, mental illness signifies an alteration of that well-being.

Substance abuse also affects millions of people in the United States each year and refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Substance use disorders occur when the chronic use of alcohol or drugs causes significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school or home.

WHAT INSURANCE BENEFITS ARE 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.

Please note: The information contained on this site is restricted to the requirements of Florida fully regulated, commercial (individual and group) health policies and contracts. The Department does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974 (ERISA), employer group health plans issued outside the State of Florida, Medicaid, Medicare, Tricare, or any other governmental health plan. Please see our Tips section to determine the correct state or federal agency for these types of coverage.

REQUIREMENTS FOR COVERAGE BY GROUP HEALTH PLANS UNDER FLORIDA LAW

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 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:

  1. 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.
  2. 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.
  3. 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.

THE FEDERAL MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT

The federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to eliminate coverage discrimination between policyholders or members who are seeking mental health or substance use disorder (MH/SUD) benefits and those seeking medical and surgical care. 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 phig@cms.hhs.gov. 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.

Please note: The state’s authority is limited to fully regulated, commercial (individual and group) health policies and contracts in Florida. The Department does not have authority over self-insured plans under the Employee Retirement Income Security Act of 1974 (ERISA), employer group health plans issued outside the State of Florida, Medicaid, Medicare, Tricare, or any other governmental health plan. Please see our Tips section to determine the correct state or federal agency for these types of coverage.


Individuals needing our assistance with mental health or substance use disorder benefits can contact our office by:


Behavioral Health Care Services Frequently Asked QuestionsBehavioral Health Care Services Tips