Claiming insurance for your mental health care is often more difficult than it should be, especially because your condition may affect your stress level and ability to deal with policy details. Knowing as much as possible about your health insurance policy will help you understand what you can claim and how to get the best mental care available.
Some insurance companies may have different rules regarding mental health care than those for physical health care. While there are efforts being made to prevent this, understanding key terms relating to your treatment and your policy can help you stay in control of both. It is important to know your rights, as well as areas where you may experience difficulties, in order to plan your treatment in advance. This way, you will not need to waste time and energy during the course of your treatment and can instead focus on improving your mental health.
Mental Health Care as an Essential Health Benefit
Mental health care is one of the ten types of care that must be covered by health insurance. The exact treatments covered by your insurance plan will vary, but there should be some type of coverage. Marketplace health insurance plans cannot put dollar limits on your mental health coverage or deny you coverage because of a pre-existing mental health condition.
Many health insurance plans should also provide “parity” between mental health care coverage and other health care, according to the Mental Health Parity and Addiction Equity Act (MPHAEA). This means the company may not demand a higher copay or deductible for your mental health care treatments. They also may not put stricter limits on the days allowed for treatment or the rules regarding your case management.
Checking Your Policy
Every health insurance policy will vary, particularly when it comes to mental health care coverage. Because of this, it is vital to check your policy thoroughly before seeking treatment. Below are some points to look at on your policy:
- Referrals from your primary care physician may be necessary before seeking treatment from a mental health professional. The company may deny your claim if you do not obtain a referral.
- Pre-approval might be required from the company itself before you seek mental health treatment. This may be before a course of treatment or before every visit.
- In-network providers of mental health care may be provided as a list from which you must choose. If you have the option of choosing an out-of-network provider, you may have a higher copayment as a result.
- Coverage limits may apply, such as a dollar amount or a limit on the types of treatment sessions you may attend.
- Available procedures and treatments may be provided as a prescriptive list. You will need to limit your treatment options accordingly.
- Covered diagnoses may also be specified. If your diagnosis falls outside of the coverage list, your claim may be denied.
- Medications are commonly used to treat mental health conditions. You may be limited to certain preferred drugs or generic brands.
- Copayments are the amount you will have to contribute to your mental health medical bills. These should not be higher than those for regular medical bills, according to the Parity Law.
- Deductibles, or the amount you must pay before your insurance will make a payment, should also be the same for mental health care as other health care in your policy.
- Parity law applies to many insurance plans but not all of them. If your insurance plan does not fall under parity law, it is vital to find this out as soon as possible.
Types of Treatments Available
When planning your treatment, you need to understand what types of treatment your policy will cover and to what extent. This will enable you to work together with your mental health provider to come up with an affordable plan. Your insurance might cover the following mental health treatment types:
- Psychotherapy, such as talk therapy and behavioral therapy, provided through sessions with a psychologist, therapist, counselor or other mental health professional.
- Medication is often paired with some form of therapy and can help you manage your mental condition.
- Hospitalization might be required in some cases and may be covered under inpatient treatments.
- Substance use disorder treatments will vary and may be referred to as “substance abuse” treatment in a health insurance policy.
Medicare, Medicaid and CHIP
If you are enrolled in Medicaid, you will be covered for at least some types of mental health treatments. The specific treatments available to you will vary by state. The treatment available to children enrolled in the Children’s Health Insurance Program (CHIP) should provide any essential mental health benefits. This includes substance use disorder benefits.
Medicare covers several types of mental health treatments within its various categories. For example, Medicare Part A covers hospital visits, so it also covers hospitalization for a mental illness. Part B, medical care, covers outpatient mental health treatments, and Part D covers medications. The exact treatments available, however, will vary depending on your plan.
Dealing With Insurance Issues
If you have been denied mental health coverage for any reason or if your policy is difficult to understand, it is important to seek help. If you have workplace health insurance, ask to speak to your Human Resources department. Otherwise, seek help from your doctor’s office or from a friend or family member.
If you suspect your insurance policy is not in compliance with Parity Law, you should request a summary of your benefits and coverage. You may also contact the U.S. Department of Labor’s Employee Benefits Security Administration for further assistance. For issues with private insurance, contact your state Insurance Commissioner’s office or state Insurance Department.
Some mental health providers will not accept insurance, as the rate of reimbursement can be very low. Because of this, it is important to check whether your insurance will be accepted before starting any kind of treatment. If you have workplace health insurance, you should mention any refusals to your Human Resources department, as they may need to change their rates of reimbursement.