But I was told I have insurance coverage for mental health.
Insurance coverage is an extremely complicated topic, with so many changing variables one can hardly keep up. However, there is always one question that arises time and again. If a policy states it provides coverage for mental health, why is it so hard to access?
First of all, let’s be clear about insurance coverage. Although not required, almost all insurance plans provide some coverage for mental health. In fact, all policies purchased on the Affordable Care Act (a.k.a. Marketplace or ObamaCare) provide some level of mental health and substance abuse treatment coverage. Now for the fine print – exactly what level will vary depending on the policy purchased. In an effort to ensure more coverage for mental health, the Federal Parity Law was passed in 2008, requiring insurance plans to cover behavioral health and physical health equally. Additionally, some states passed their own laws, thus providing even better parity. However, these laws do not regulate how companies dole out these benefits.
Time and again I hear from parents quoting their plan booklet: they are allowed “X” number of sessions per year or “X” amount of residential treatment or behavioral health hospitalization. What is not always made clear, and buried in the fine print, are the limitations or controls placed on these benefits. Here are some good examples:
Jane wants to see a therapist, but her plan pays a higher rate if she sees someone “in-network” (meaning this professional has already agreed to a payment maximum allowed by the insurance). If Jane chooses someone “out-of-network,” the reimbursement is significantly lower. In some cases, plans do not allow for any reimbursement out-of-network.
Johnny is in need of residential treatment. The program his parents would like to choose is licensed by their state. The insurance plan only provides for coverage if the treatment center is accredited by an additional entity (e.g. The Joint Commission or CARF). Even if the treatment center is legally allowed to operate in the state, the insurance company is not required to cover it.
These are just two of dozens of tricky scenarios that can arise. Other factors such as “service area”, “self-funded vs. fully funded plans”, and agencies hired to manage behavioral health benefits can all add to the confusion.
However, there are ways to make sure you are aware of your coverage and don’t get blind-sided. Verify your benefits directly with your insurance company. Call the referenced number on the insurance card. Make sure to ask the following questions:
What are the policy’s benefits for mental health? Get specifics on the number of sessions, days, etc.
Ask if “out-of-network” benefits are permitted and what is the cost difference in coverage.
Ask if accreditation, as well as state licensing, are required when seeking in-patient or residential treatment.
Ask about additional requirements like 24/7 nursing or the presence of a clinician 24/7.
Ask for the name of the person verifying the benefits and a reference number.
If all of this seems too daunting, there are wonderful insurance advocates that can be hired to act on your behalf, even going to bat for you if the insurance company denies coverage*. While this may seem like an added cost, they usually pay for themselves by assisting you in recouping reimbursement you may have otherwise never seen. Remember, half of something is better than all of nothing.
REMEMBER, insurance companies are businesses with the goal of turning a profit. Dealing with insurance companies can be exhausting and frustrating but the most important thing you can do is be your own best advocate. You have pre-paid your health insurance premiums precisely for help in this time of need. What you or even your mental health providers may believe is best for your circumstances may be vastly different from what the insurance company believes is best.
As you are searching the website for facts about treatment, be sure to implement the age filter (pre-teens, teens, or young adults) to review which treatment to transition options have had some success with insurance or might even be in the network.
* Insurance Advocates have different ways of getting paid too, so interview a couple to gain a sense of the process.
If you are looking into getting insurance reimbursement for Wilderness Therapy, listen to this podcast.
About the Author
Elizabeth McGhee, LCSW, is an Independent Educational Consultant and Therapeutic Consultant at the Aspire Group who has over 30 years of experience helping families, young adults, and adolescents. She was previously the Director of Admissions and Outreach for several highly regarded residential treatment programs and assisted all families with demystifying insurance.