Mental Health Parity and Addiction Equity - Patients

The term "provider" as used on this page is intended to reference behavioral health providers of all types including individual providers, group providers and institutions.

In-Network Coverage 

Whether you have insurance limited almost exclusively to coverage under a singular network like the traditional HMO, or you have insurance covering both In-network and out-of-network treatment (with differing coverage levels), for these plans you should be able to look at the in-network provider lists to locate in-network behavioral health provider options.

LOCATING AN IN-NETWORK PROVIDER - As an initial challenge, in many areas,  you may find a very limited number of available providers that can actually provide you the timely treatment you require.  Insurance in-network provider lists at times include providers that have moved out of the area, retired, or even passed away.  Once you locate an actual in-network provider located in your area there can be problems of severely limited availability to accommodate new patients.  Sadly, it is not unusual for listed in-network providers to fail to even respond to calls relating to new patient requests for a meeting.  This process can be incredibly frustrating and overwhelming.  Please know you are not alone.  Many of us have lived this struggle again and again and know how incredibly difficult this part of obtaining help can be.  Until greater work can be undertaken to analyze actual network availability and to have any identified deficiencies remedied, persistence and commitment in calling and re-calling will likely be required and is crucial.  Once you locate an available in-network provider, keep in mind that in-network coverage should generally be subject to, and be credited under, the same deductibles, copays, co-insurance and out-of-pocket amounts as your other covered medical expenses.

Out-of-Network Coverage

If your insurance plan includes out-of-network coverage options, you may opt to seek behavioral health treatment from an out-of-network provider.  Most out-of-network providers will expect direct and prompt payment from you and will provide to you a bill/invoice that may then be submitted by you to the insurance company for reimbursement.  A few out-of-network providers may actually have a biller who will submit to your insurance company on your behalf, but that practice is extremely uncommon.  

LOCATING AN OUT-OF-NETWORK PROVIDER - Although the behavioral health field is overwhelmed in many areas of this country, locating an available out-of-network provider (if that is an option available to you under your insurance plan) can often be easier and faster for establishing much needed care than the path to establishing care with an in-network provider.  Unfortunately, as with other medical treatments, using an out-of-network provider will almost always involve higher deductibles and lower coverage rates than using an in-network provider.  Please keep in mind that out-of-network amounts for deductibles, copays, out-of-pocket maximums, etc. are almost always separated from the same in-network amounts and so you will usually "start-over". from what you have already paid for the year for in-network medical services, when considering and totaling costs for out-of-network treatment.  Please try not to become too discouraged if you find that out-of-network treatment is basically the only realistic, timely approach for your behavioral health treatment.  You are not alone in this struggle and it is the reason we hope to do everything we can short-term and long-term to address the very real problems with the behavioral health system.

GETTING THE REIMBURSEMENTS YOU ARE OWED - Assuming you have health insurance with out-of-network coverage options and you are seeking behavioral treatment with an out-of-network provider, in order to receive the financial reimbursement you may be owed for payments you made for your out-of-network behavioral health treatment, you or someone form your support team will need to timely submit the bill/invoice to your insurance company.  Your insurance company will either have paper documents to be filled out and mailed in along with the provider's bill/invoice.  Alternatively, becoming more common, your insurance company may have an online portal where you can fill out questions online and upload a picture/copy of the provider's bill/invoice.  The process can seem daunting and exhausting at times, but again we hope you may derive a sense of support and added determination in knowing that you are not alone and that many, many of us struggle with this hurtle.  The insurance companies almost always require some form of "Superbill" from your provider.  Your provider should know what this billing type is and should be able to provide it to you.  If not you can try working with whatever billing documentation your provider gives to you and ask that they include additional pieces of information as your insurance company may request.  A Superbill, generally, includes the name and address of the provider; the provider's NPI number [National Provider Identifier number]; the provider's EIN number [Employer Identification Number]; the relevant diagnosis code(s) for your treatment [usually ICD-10-CM codes]; the date(s) of service; the CPT code(s) for each date of service [Current Procedural Terminology codes]; charged amount for each date of service; POS designation code [Place of Service code; often "11" for being seen in office or "10" for a virtual visit].  There will likely be a few additional items not described here.  Generally, on the papers you are submitting to the insurance company for reimbursement, you will want to hand write something like "Please Reimburse Subscriber Directly" and include the Subscriber's name immediately following that stated request.  [The "Subscriber" is the primary holder of your insurance coverage - you, your spouse, etc.]  This additional writing on the Superbill should be used if you already paid the provider and the insurance reimbursement should come to you rather than the provider.

For BOTH In-Network or Out-of-Network Treatment

STAND UP FOR YOURSELF - This section is parallel information to the secondary challenge section we mentioned directly above in the in-network discussion.  Tracking all behavioral health treatment dates together with keeping copies of all  bills/invoices in some orderly system comfortable for you can be critical.  Your insurance company should be providing you with an EOB [Explanation of Benefits] for each behavioral health treatment session whether the session amount is counted as part of your deductible and even if no amount is paid by the insurance company for that session, or whether some part of the session is paid by the insurance company. The information on the provided EOBs should parallel the information being provided on other medical treatment EOBs from your insurance company.  For behavioral health EOBs, it can be very valuable to double check the insurance handling of each behavioral treatment session in order to ensure you are receiving all amounts to which you are entitled.  Even if it takes help from someone within your support system, matching up each insurance EOB you receive with your behavioral health treatment sessions and keeping copies in some system that works for you is the only way to confirm over time that correct payments/reimbursements for behavioral health treatment are being made by your insurance company and documentation will be necessary to present and rectify mis-payments.

FACING POTENTIAL CHALLENGE TO COVERAGE - When treated as is intended under parity and equity laws, your insurance company can subject your covered behavioral health treatment plan to scrutiny based on the insurance company's self-imposed standards relating to medical necessity.  Relating to this scrutiny, as with your other covered medical treatment, your covered in-network behavioral health treatment can be subject to requests for medical records (although therapy notes at times can be subject to different handling rules).  If an issue of medical necessity or medical records arises, hopefully, you can have a direct and open discussion with your provider regarding how best to address any concerns and simply provide information acceptable to your insurance company.

FURTHER ASSISTANCE - If you need assistance with a parity problem or simply trying to understand how to get insurance coverage for behavioral health treatment, please do not hesitate to reach out and we will try to help.  Please understand we do NOT provide legal advise or similar professional advise.  We are simply folks trying to balance the scales a bit and all assistance should be reviewed by legal or other professional advisors.  Any and all assistance is being provided "as-is, where-is, without any specific purpose or specialty".

IMPORTANT NOTE FOR THOSE WANTING TO UNDERSTAND MORE:
Probably one of the worst offenders (and most effective tactics) in limiting the effectiveness of new Mental Health Parity and equity laws rears it ugly head after you clear the hurtle of self submitting for reimbursement.  Your behavioral health treatment reimbursement will most likely be subject to much higher deductibles, higher copays, higher co-insurances and significant high out-of-pocket maximums as out-of-network treatment.  Insurance companies have been very aware from before Mental Health Parity laws were accepted that a significant amount of behavioral health treatment in this country is provided by out-of-network providers for a whole host of historical reasons.  Following the legal changes, in a striking move, many of the out-of-network limits skyrocketed even further.  In addition, in most cases, your reimbursements for out-of-network treatment will be even further reduced by pre-determined cap amounts that your insurance plan will apply to each item on your provider's bill.  These caps apply before any billed amounts are considered toward deductibles, copays, co-insurances and out-of-pocket maximums (all if which will likely already be fairly high as described).  Plans sometime refer to these caps as "Maximum Allowable Amounts" (MAAs) or "Reasonable and Customary Amounts" (R&C's) or similar labels.  An intensive study, discussion, and counter of these caps is an imperative next step.