Patient Protections
Know Your Rights
Protections exist in most major health plans—and they’re stronger than most people realize. They don’t solve every problem, but they do give patients leverage. Few people know these rights exist because they aren’t advertised. Understand what tools for pushback exist and share them with your community.
Insurance Protections You Can Utilize Now
Single Case Agreements/Appeals (SCA): If your therapist or specialist is out of network, you or your provider can request a single case agreement—a one-time contract where your insurer agrees to cover that provider at in-network rates. Available at most major plans. Rarely proactively offered.
How to use it: Call your insurer’s member services or provider relations team and ask specifically for a “single case agreement.” Your provider should write a letter of medical necessity explaining why no adequate in-network provider is available for your specific condition.
Continuity of Care Protection: If your therapist or psychiatrist leaves your insurer’s network, many states require the plan to continue coverage for an ongoing course of treatment—often 90–180 days—at in-network rates while you transition. Most patients are never told that this right exists.
How to use it: Request a continuity of care form from your insurer immediately when a provider leaves the network. Do not wait. State laws vary—check your state insurance commissioner’s website for your state’s specific rules and timelines.
Network Adequacy Complaint: Insurers are legally required to maintain networks with enough mental health providers to serve members within reasonable time and distance standards. If you cannot find an available in-network therapist or psychiatrist, your insurer may be violating network adequacy requirements.
How to use it: Document your search: dates, providers contacted, waitlists, and time/distance to available providers. File a complaint with your state insurance commissioner (fully insured plan) or the DOL EBSA (employer self-funded plan). Many states will then require the insurer to grant out-of-network access at in-network cost-sharing.
Mental Health Parity and Addiction Equity Act (MHPAEA) Parity Violation Filing: Federal law requires health plans to cover mental health and substance use disorder treatment no more restrictively than comparable medical or surgical care.
How to use it: Request your plan’s MHPAEA comparative analysis in writing. If a denial seems inconsistent with how comparable medical care is treated under your plan, file a parity complaint with your state Department of Insurance (fully insured plan) or the DOL EBSA (employer/self-funded plan).
Formulary Exception/Tier Exception: If your psychiatric medication is on a high-cost specialty tier or excluded from your formulary, you can request a formulary exception—asking the plan to cover it at a lower cost tier or at all. This is different from an appeal and should be tried first.
Remember: Exception = change the rules upfront. Appeal = fight a denial after the fact.
How to use it: Have your doctor submit a formulary exception request with a medical necessity letter before the medication is dispensed if possible. This is faster than an appeal and sets up a stronger case if denied. Both exception and appeal rights are required for ACA-compliant plans.
External Independent Review: After exhausting your insurer’s internal appeals, you have the right to an external review by a neutral third party not connected to your insurer. External reviewers overturn insurer decisions at meaningful rates. This applies to all non-grandfathered ACA-compliant plans.
How to use it: After your final internal appeal denial, request external review through your state’s process (fully insured plan) or the federal external review process (employer plan). Time limits apply—typically 4 months from final denial. Do not delay in requesting this.
Resources:
Find your state insurance commissioner department: content.naic.org/state-insurance-departments
Contact the Department of Labor Employee Benefits Security Administration:https://www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa
Get support filing your parity complaint + get step-by-step appeals guidance: parityregistry.org
Push your state: Contact your state medical society or NAMI state affiliate to find active bills.
Track state-based parity legislation:paritytrack.org
Additional helpful links:
