Key takeaway
You were told substance use visits are capped when other medical visits are not. Parity compares those limits with medical and surgical care when a plan covers substance use benefits. It does not by itself force every plan to offer the benefit. Tonight, ask for the denial reason in the plan's own words.
Last updated: Mon Oct 05 2026 00:00:00 GMT+0000 (Coordinated Universal Time)
The plan capped your substance use visits, or it demanded approval it does not demand for other hospital care. You need to know whether that difference is allowed, and what to ask for tonight.
If you are in medical danger, call 911. For a mental health crisis, call or text 988.
Compare the limit with medical care in the same category
When a plan covers substance use benefits, those limits cannot be tighter than the limits on medical and surgical care in the same classification. Copays, visit caps, and prior authorization are the usual hurdles. The law does not, by itself, require every plan to cover substance use care. If the plan does cover it, the comparison applies. Non-grandfathered individual and small-group plans have a separate coverage requirement under the Affordable Care Act. Your documents say which situation you are in.
One illustration from the Department of Labor: if the plan does not cap outpatient physical health visits, it should not cap outpatient substance use visits. A residential stay is compared with inpatient medical care, not with an office-visit copay. Prior authorization can exist on both sides. The parity question is whether the substance use version is stricter. Appeal the denial letter in the plan's own words.
Ask for the reason in their words
Tonight, ask the plan for the benefit description and for the medical-necessity criteria it used. If you think the limits are uneven, CMS lists a help line at 1-877-267-2323, extension 6-1565. DOL benefits advisors answer at 1-866-444-3272. Medicaid is a separate door.
We check benefits before you commit. That check can ask about network status, what you might owe, and whether the plan wants authorization. Call or text (800) 653-9376 if you want that conversation tied to a referral.
Additional Resources
Sources cited on this page:
- CMS: The Mental Health Parity and Addiction Equity Act (MHPAEA)
- CMS fact sheet: The Mental Health Parity and Addiction Equity Act of 2008
- U.S. Department of Labor: Mental health and substance use disorder parity
- DOL: Know your rights, parity for mental health and substance use disorder benefits
- 988 Suicide & Crisis Lifeline
Common Questions
Does parity mean my plan has to pay for rehab?
Not by itself. MHPAEA does not require group health plans or insurers to cover mental health or substance use benefits. If they do cover them, the financial requirements and treatment limits cannot be more restrictive than the predominant limits on medical and surgical benefits in the same classification. The Affordable Care Act adds a coverage requirement for those services as an essential health benefit in non-grandfathered individual and small-group plans. Your plan documents say which rule applies.
What is a quantitative limit?
Quantitative limits are numbers, such as visit limits and day limits. Visit limits on mental health or substance use care cannot be more restrictive than the limits on medical or surgical visits for a majority of plans. If a plan does not cap outpatient physical health visits, the illustration is that it should not cap outpatient substance use visits. That is an illustration of the rule. Your plan documents say what your card actually does.
What is a non-quantitative limit?
These are rules that are not a count. Examples include medical management, step therapy, prior authorization, network makeup, and how out-of-network rates are set. The processes used for substance use care have to be comparable to those used for medical and surgical care in the same classification, and applied no more strictly. A prior authorization rule can exist. A stricter one, with no counterpart on the medical side, is the parity question.
Does this apply to Medicaid and Medicare?
Medicare, Medicaid, and CHIP are not group health plans or insurance issuers. Separate rules require certain Medicaid managed care plans, CHIP, and Medicaid benchmark plans to comply with some parity requirements. Employer coverage is a different door. Ask the plan administrator whether the coverage is insured or self-funded.
Who do I call if the limits look uneven?
CMS lists a help line at 1-877-267-2323, extension 6-1565, and [email protected]. DOL benefits advisors answer at 1-866-444-3272. Ask the plan for the benefit documents and for the medical-necessity criteria it used. Bring the denial reason in the plan's words to any appeal.