A person with a diagnosis of schizophrenia will be able to receive the same care in regards to utilization and out-of-pocket expense for an intensive, inpatient hospitalization as someone with a need for intensive, inpatient hospitalization for a medical/surgical condition. Appeals Process Overview You have a legal right to challenge a coverage denial by a health plan, no matter what kind of health plan you have. For example, you have a right to challenge a coverage denial if you have an individually-purchased plan or an employer-paid plan. This includes plans available directly, or through a broker or an exchange, such as Covered California. Every plan is required to provide a process to reconsider or appeal a denial of coverage. The only question should be who to file the appeal with and which parity law applies. If your health plan is regulated by the State of California, and you have been diagnosed with one of the nine mental illnesses listed on page 5, or a severe emotional disturbance, as defined on page 5, this toolkit provides the materials to help you with your appeal. If you fall outside of these criteria, you most likely fall within the federal parity laws and the federal toolkit would be the best resource. The federal toolkit can be located at . Regulating agencies If you have a health care service plan, also called a managed care plan, or a Blue Cross or Blue Shield preferred provider organization (PPO) plan, your plan is probably regulated by the California Department of Managed Health Care (DMHC) and DMHC rules apply to your plan. If you have an indemnity insurance policy (also called a plan) including a “fee-for-service” PPO plan (other than a Blue Cross or Blue Shield PPO plan) your plan is probably regulated by the California Department of Insurance (CDI, or DOI), and CDI rules apply to your plan. The California Mental Health Parity Act provisions administered by DMHC and CDI are virtually the same, but are found in different places in the California codes. The statutes administered by DMHC are found in the California Health and Safety Code and the statutes administered by CDI are found in the California Insurance Code. DMHC and CDI also apply federal mental health parity protections
A person with a diagnosis of schizophrenia will be able to receive the same care in regards to utilization and out-of-pocket expense for an intensive, inpatient hospitalization as someone with a need for intensive, inpatient hospitalization for a medical/surgical condition. Appeals Process Overview You have a legal right to challenge a coverage denial by a health plan, no matter what kind of health plan you have. For example, you have a right to challenge a coverage denial if you have an individually-purchased plan or an employer-paid plan. This includes plans available directly, or through a broker or an exchange, such as Covered California. Every plan is required to provide a process to reconsider or appeal a denial of coverage. The only question should be who to file the appeal with and which parity law applies. If your health plan is regulated by the State of California, and you have been diagnosed with one of the nine mental illnesses listed on page 5, or a severe emotional disturbance, as defined on page 5, this toolkit provides the materials to help you with your appeal. If you fall outside of these criteria, you most likely fall within the federal parity laws and the federal toolkit would be the best resource. The federal toolkit can be located at . Regulating agencies If you have a health care service plan, also called a managed care plan, or a Blue Cross or Blue Shield preferred provider organization (PPO) plan, your plan is probably regulated by the California Department of Managed Health Care (DMHC) and DMHC rules apply to your plan. If you have an indemnity insurance policy (also called a “fee-for-service” plan) including a PPO plan (other than a Blue Cross or Blue Shield PPO plan) your plan is probably regulated by the California Department of Insurance (CDI, or DOI), and CDI rules apply to your plan. The California Mental Health Parity Act provisions administered by DMHC and CDI are virtually the same, but are found in different places in the California codes. The statutes administered by DMHC are found in the California Health and Safety Code and the statutes administered by CDI are found in the California Insurance Code. DMHC and CDI also apply federal mental health parity protections
CM5401.docx