Mental health has become one of the most important healthcare issues facing Texas families and employers. Anxiety, depression, substance use disorders, and other behavioral health conditions affect our workplaces, families, schools, and communities.
Yet there is an important protection available to Texans that surprisingly few people seem to know about:
Mental health and substance use disorder benefits generally cannot be treated as second-class healthcare benefits.
Texas has a mental health parity law, strengthened by House Bill 10 in 2017, that requires applicable health plans to provide mental health and substance use disorder benefits under the same terms and conditions as medical and surgical benefits. The law applies not only to obvious financial limits but also to less visible restrictions that can make accessing behavioral healthcare more difficult.
What Does “Mental Health Parity” Actually Mean?
Parity does not necessarily mean that every mental health service must be covered or that every provider must be in-network.
It means that when mental health and substance use disorder benefits are covered, health plans generally cannot impose restrictions on those benefits that are more restrictive than the limitations placed on comparable medical and surgical care.
That can include things such as:
● Deductibles, copayments, and coinsurance
● Limits on treatment or office visits
● Prior authorization requirements
● Medical-necessity standards
● Prescription drug formularies
● Provider-network requirements
● Inpatient and outpatient treatment
● Emergency services
Texas law specifically addresses both quantitative treatment limitations, restrictions that can be expressed numerically, and nonquantitative treatment limitations, which are often less obvious to consumers.
That second category is especially important.
A health plan might appear to provide excellent mental health benefits on paper. But what happens if it is significantly more difficult to obtain authorization for behavioral healthcare than for comparable medical treatment? What if the provider network makes accessing covered mental healthcare unusually difficult? What if medical-necessity standards are applied more restrictively?
Those are the types of issues parity laws are intended to address.
Mental Health vs. Behavioral Health: What Is the Difference?
Before discussing parity, it helps to understand two terms that are frequently used as though they mean the same thing: mental health and behavioral health.
Mental health generally refers to a person’s emotional, psychological, and social well-being and to conditions affecting those areas. Depression, anxiety disorders, bipolar disorder, schizophrenia, and post-traumatic stress disorder are examples of conditions commonly associated with mental healthcare.
Behavioral health is a broader term. It includes mental health but also focuses on behaviors and habits that affect a person’s physical and emotional health. This is why behavioral health commonly encompasses mental health conditions and substance use disorders, along with issues involving behaviors that influence overall health.
A simple way to think about it is:
Mental health is part of behavioral health, but behavioral health extends beyond mental health.
The terminology matters when discussing insurance. A health plan may use terms such as “behavioral health services” or “behavioral health benefits” rather than simply “mental health.”
That does not necessarily mean mental healthcare is excluded. In many plans, behavioral health is the umbrella category under which mental health and substance use disorder services are administered.
This can be confusing for consumers.
Someone looking through an insurance company’s website or provider directory for a “mental health” benefit may instead find a section labeled Behavioral Health. An employee looking for help with alcohol or drug dependency may not realize that those services can fall under the same general behavioral health benefit structure.
And that brings us to an important point about parity.
The federal Mental Health Parity and Addiction Equity Act and Texas parity requirements address mental health and substance use disorder benefits in comparison with medical and surgical benefits. In other words, parity is not limited to what most people traditionally think of as “mental health.”
It also includes protections involving treatment for substance use disorders.
That distinction is especially important because stigma and terminology can become barriers themselves. People may not know what benefit to look for, what services are covered, or what questions to ask their insurance company.
Why This Matters to Employees
Imagine an employee struggling with depression who opens their health plan’s website and sees no obvious button labeled “Mental Health.” Instead, the plan lists Behavioral Health.
They may assume they do not have mental health coverage.
Or consider an employee who needs treatment for a substance use disorder. They may not realize that federal and Texas parity protections can apply to substance use disorder treatment as well.
That is why employers and insurance agents should explain the terminology when reviewing benefits:
Mental Health — emotional and psychological health and treatment of mental health conditions.
Substance Use Disorder — treatment related to alcohol, drugs, and other substance use disorders.
Behavioral Health — the broader umbrella term frequently used to encompass both mental health and substance use disorder services, and sometimes other health-related behavioral services.
Knowing the terminology may sound like a small thing, but it can determine whether someone knows where to turn for help.
And that gets to the larger problem with mental health parity in Texas: having a legal protection doesn’t do much good if people don’t know it exists, or don’t even know what their health plan calls the benefit.
Texas Strengthened Its Law in 2017
Texas took a significant step when the Legislature passed House Bill 10 in 2017.
The legislation expanded the Texas Department of Insurance’s authority over mental health parity and addressed both quantitative and nonquantitative treatment limitations. The legislation became effective September 1, 2017, with its new parity provisions applying to applicable health plans issued or renewed beginning January 1, 2018.
Texas Insurance Code §1355.254 now requires applicable health benefit plans to provide mental health and substance use disorder benefits under the same terms and conditions as medical and surgical benefits and prohibits generally more restrictive treatment limitations.
That is a significant consumer protection.
Yet ask the average employee what “mental health parity” means, and there is a good chance they have never heard of it.
Having a Right Doesn’t Help Much If You Don’t Know You Have It
This may be one of the biggest problems with mental health parity.
We have spent years talking about expanding access to mental healthcare, and appropriately so, but considerably less time educating people about the insurance protections they may already have.
An employee whose behavioral health treatment is denied may simply assume: “My insurance doesn’t cover it.”
A parent struggling to find appropriate treatment for a child may assume there is nothing else they can do.
Someone facing substance use disorder may give up after encountering an authorization barrier.
But a denial isn’t necessarily the end of the process.
The Texas Department of Insurance advises consumers to ask why mental health treatment was denied and to use their health plan’s appeal process. Depending on the circumstances, consumers may also have access to an independent external review. Consumers and healthcare providers who believe a health plan is violating Texas insurance law can also file a complaint with TDI.
Know What Type of Health Plan You Have
There is another complication that makes consumer education particularly important. Not every employer health plan is regulated by Texas.
Fully insured health plans are generally regulated by the Texas Department of Insurance. Self-funded employer plans are generally regulated under federal law rather than state insurance law.
TDI offers a useful shortcut: if a health plan is fully insured, the insurance identification card should indicate “TDI” or “DOI.”
This distinction matters because it determines where an employee should turn when there is a problem.
Employers and Insurance Agents Can Help
Employers spend substantial amounts of money providing health insurance, but employees don’t always understand the benefits available to them.
Mental health parity education should become part of that conversation.
Benefits professionals, insurance agents, HR departments, and employers should consider explaining mental health benefits during enrollment, not simply listing “Mental Health” as another line on a benefits summary.
Employees should know that behavioral healthcare is healthcare.
They should know what their plan covers.
They should know where to find an in-network mental health professional.
And perhaps most importantly, they should know that a denial does not automatically mean they have reached the end of the road.
Awareness Is Part of Access
We often talk about healthcare access as though the only issue is whether someone has an insurance card.
Coverage is only the first step.
Real access means understanding how to use that coverage and knowing what protections exist when something goes wrong.
Texas has had strengthened mental health parity protections for years. The Texas Department of Insurance continues to maintain parity rules, collect information from insurers, conduct compliance analyses, and provide resources for consumers.
But laws cannot protect people who don’t know those protections exist.
That is why employers, agents, healthcare providers, insurers, nonprofits, and state agencies should be talking much more about mental health parity.
If even one employee struggling with depression, anxiety, addiction, or another behavioral health condition learns that they have options they didn’t know they had, that education matters.
Mental health parity shouldn’t be one of Texas healthcare’s best-kept secrets.
Where Texans Can Get Help
The Texas Department of Insurance provides information about mental health and substance use disorder parity, appeals, and complaints. Consumers who have questions about an insurance claim or believe their rights may have been violated can contact TDI’s Help Line at 800-252-3439.