Understanding and Navigating Insurance for Mental Health Treatment

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When adolescents need mental health services, one of the first questions their parents ask is often, “Will insurance cover treatment?” followed by “How do we work with our insurance company?”

To help parents best understand — and navigate — the insurance process, Laurie Brown, vice president of revenue cycle management at Embark Behavioral Health, a nationwide mental health services provider for teens and young adults, answered five key questions.

1. Where Should Parents Start When It Comes to Understanding and Using Insurance Coverage?

Many individuals are not familiar with their insurance coverage. The first rule of thumb is to become acquainted with the insurance policy. The member identification card has a wealth of information and should clearly outline who the mental health carrier is. Always share the front and back of the card with the provider to reduce confusion or errors since the medical and mental health carriers may not be the same organization.  

During insurance enrollment, the member is provided with a summary of benefits and coverage. Always keep this available to ensure there’s a concise understanding of the insurance plan and coverage. Parents should also obtain a copy of the certificate of coverage or summary plan description from the insurance company. This lengthy guide will help them understand what the specific plan will and will not cover. Also, don’t hesitate to ask for coverage criteria for the needed treatment. 

Try to find a provider who’ll work with the insurance as an in-network or out-of-network provider. If parents are using an out-of-network provider, they need to understand most policies require more out-of-pocket expenses in the form of deductibles and coinsurance payments.  

2. What Should Parents Keep in Mind When Choosing Mental Health Providers for Their Adolescents? 

Quality of care should always be a primary consideration. Look for referrals to understand if others are sharing positive outcomes from and experiences with the provider of choice. Parents should also consider:

  • What services are needed, and does the provider have a success rate with the specific needs? 
  • How affordable is the care? 
  • Will the provider bill the insurance for the services rendered? 
  • How involved in the insurance billing is the provider? 

If the family is dependent on insurance coverage for treatment, look to find an in-network provider. If they can’t find a suitable in-network provider, work with the out-of-network provider to pursue a single case agreement or in-network exception. These two options serve members well if approached from the right angle. 

  • A single case agreement is an individual agreement or authorization between an out-of-network provider and an insurance company. It will have negotiated reimbursement rates established upon receipt of the authorization. 
  • An in-network exception is an authorization provided to an out-of-network provider where in-network benefits are honored, including deductible and coinsurance percentage. Reimbursement rates for what the insurance company will pay to the provider are not negotiable at the time of authorization for an in-network exception.

3. What Challenges Do Parents Often Face When Navigating Insurance for Mental Health Care? 

Just as there are many services provided under medical health care, there are also many services for mental health care. The first challenge is to identify a provider who understands the insurance world for this type of treatment.  

Many providers will require upfront payments and provide a statement or superbill for the member to submit to the insurance company. If parents are preparing their own claims, they should take time to research claim requirements. This will aid in avoiding unnecessary delays or denials. 

In addition, keep in mind that sometimes, more care is required than the insurance is willing to pay. Make sure to identify the anticipated length of treatment and understand if the insurance company will cover some or all of it.

4. What Should Parents Do If the Insurance Company Denies Coverage?

When coverage is denied, you have the right to challenge the denial through the appeals process. The process can be managed by the insurance plan participant, the provider, or an independent insurance advocate who specializes in appeals.

There are multiple levels of appeals, with the first level referred to as an internal appeal, which is handled by the health plan. If this appeal is denied, plan participants can file a second-level appeal. If the outcome of that is not satisfactory, they can request a third-level appeal. 

The third level is considered an external review and is conducted by an independent review organization. This third party will report its findings to both the plan participant and the health insurance plan. The plan is legally obligated to honor the determination of the IRO.  

Throughout the appeals process, it’s important to ensure all medical documentation is obtained, thoroughly reviewed, and compared to the plan requirements. Understanding medical necessity requirements is key to documenting the need for services. Appeals should be carefully scripted to point to medical necessity and to demonstrate the value of the services provided.  

Finally, make sure to submit appeals to the correct party and in a timely manner.

5. What Resources Can Parents Access To Help Them Navigate Insurance for Mental Health Care? 

Two resources immediately come to mind:

  • Human resources: If parents have a self-insured plan, meaning the employer pays for claims, the HR department may lend assistance with questions regarding claims. Don’t hesitate to ask them to make an exception or remove roadblocks for the needed coverage. 
  • Insurance advocates: Seek an insurance advocate when trying to navigate insurance without the assistance of the provider or a billing service. They’ll work with the insurance company to ensure parents are getting the most out of their benefits and can help with the appeals process for denied benefits.

Final Advice on Navigating Insurance

Overall, Brown recommended, “Be inquisitive and know there are people who have a good understanding of how to navigate the mental health insurance arena. Never hesitate to network with parents who have experienced similar challenges or consult with various providers to identify how they handle particular situations. Ask questions until you feel you understand. Stay informed about industry changes, insurance requirements, parity laws, and how to maximize your benefits.”

Embark Behavioral Health hosted a panel of industry experts for an informative discussion on how to get the most out of mental health insurance benefits. The replay is available online.

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Embark Behavioral Health

Embark Behavioral Health is a leading network of outpatient centers and residential programs offering premier mental health treatment for preteens, teens, and young adults. Dedicated to its mission of reversing the trends of teen and young adult anxiety, depression, and suicide by 2028, Embark offers a robust continuum of care with different levels of service and programming; has a deep legacy of over 25 years serving youths; works with families to adjust treatment in real time to improve results; treats the entire family using an evidence-based approach; and offers the highest levels of quality care and safety standards. For more information about Embark or its treatment programs, including virtual counseling, intensive outpatient programs (IOPs), therapeutic day treatment programs, also known as partial hospitalization programs (PHPs), short-term residential treatment, wilderness therapy, and long-term residential treatment, visit www.embarkbh.com.

Mental Health Coverage Misconceptions

Given insurance can be a complicated topic, it’s not surprising there are misconceptions about mental health coverage. When asked about some of common ones, Brown listed three:

  1. Providers do not bill insurance for services: More and more providers are billing for the services and are working to become contracted providers.
  2. Mental health coverage only has two options: private pay or insurance reimbursed. While this is true in many situations, there are other resources available to assist individuals when insurance does not cover the services or when the coverage is not adequate. “Don’t hesitate to look for additional coverage through agencies such as counties, states, or schools,” Brown said. “Network with others who’ve had similar journeys, as they can provide insight into their learnings and experience.”
  3. If authorization was denied, the insurance will not cover the services. A denied authorization does not mean services cannot be provided. There are options for appealing the decision. For example, peer-to-peer reviews involve clinicians from the provider and the insurance company discussing the case. “A provider should be willing to lend support to convince the insurance clinician of the medical need for services,” Brown said.