Ensure Your Health Insurance Provides Equal Coverage For Mental Health Benefits
Private health insurance coverage for mental health must be equal to physical health conditions. This is "mental health parity.” It is the law. If your health plan is not giving you equal coverage, you can take action. This pub tells you what to do. This pub does not cover Medi-Cal.
Co-payments, deductibles, out-of-pocket expenses, treatment limitations, prior authorization requirements, frequency of treatment, access to medications, number of visits, and days of coverage must be equal for mental and physical health conditions. This is called "mental health parity” and it is the law. If your health plan is not providing equal coverage then you can take action.
1. Submit a complaint to your health plan or health insurance company.
Contact “member services” to submit the complaint to your health plan or health insurance company. If the dispute is not resolved in your favor, you may contact the regulatory agency that oversees your plan.
2. Determine who regulates your health plan.
- Department of Managed Health Care (DMHC) oversees all HMO plans and Blue Cross of California and Blue Shield of California PPO health plans.
- California Department of Insurance (CDI) oversees most other PPOs in California.
- Department of Labor (DOL) oversees self-insured “ERISA” plans.
3. Submit a complaint to the appropriate agency.
a. DMHC. If you have an HMO Blue Cross or Blue Shield PPO and your health problem is urgent, or if you already filed a complaint and are not satisfied with your health plan's decision, contact DMHC. An urgent problem is a serious threat to your health. You can also file a complaint if your health plan does not make a decision within 30 days. The DMHC Complaint Form can be found at: http://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx
You may submit a complaint to DMHC online, by mail, or facsimile:
- Online: Complete the Independent Medical Review Complaint Form (https://www.dmhc.ca.gov/FileaComplaint.aspx).
- Mail: Complete and submit the Complaint Form to:
Department of Managed Health Care
980th Street, Suite 500
Sacramento, CA 95814-2725
- Facsimile: Complete and submit Complaint Form to (916) 255-5241
b. CDI. If you have a PPO other than Blue Shield or Blue Cross of California, submit your complaint to CDI (www.insurance.ca.gov) using the Request for Assistance Form found at: http://www.insurance.ca.gov/01-consumers/101-help/index.cfm
You may submit a complaint to CDI either online or by mail:
- Online: Complete the Request for Assistance form and submit online.
- Mail: Complete, print, and send Request for Assistance form to:
Department of Insurance
Consumer Services and Market Conduct Branch
Consumer Services Division
300 South Spring Street, South Tower
Los Angeles, CA 90013
c. DOL. If you have a self-insured “employee welfare benefit plan”, a plan that provides medical, surgical or hospital care benefits, submit your complaint to Department of Labor, Employee Benefits Security Administration (EBSA) via telephone or online,.
- Online: https://www.askebsa.dol.gov/WebIntake/Home.aspx
- Telephone: US DOL EBSA at 1-866-444-3272 or EBSA Southern California Regional Office at 1-626-229-1000
This information is provided to you through the combined effort of the following organizations:
Disability Rights California
(916) 504-5800/ (800) 776-5746
Legal Aid Society of San Diego, Inc.
Mental Health Advocacy Project
Mental Health Advocacy Services, Inc.
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