Insurance
Insurance is a crucial tool that can grant access to needed treatment to get well. Health insurance helps pay for mental health care needs including checkups, visits to specialists, emergency care and hospital stays. In most cases insurance will keep a person from paying the full cost of medical services. Getting insured or reviewing your current insurance plan may seem complicated, but knowing the basics can help you navigate the system successfully.
Types of Health Insurance
Understanding the differences among health insurance plans can help a person make an informed decision about what plan is appropriate and what options are available. The level of coverage and availability of services and mental health professionals depends on the type of plan chosen.
Common types of health insurance include:
- Private Health Insurance
- Medicaid
- Medicare
- CHIP
- TRICARE and VA Health Care
If insurance is provided through a job or government programs, there may be fewer health plans that are available to choose. If insurance is not offered by an employer or you are not enrolled in a government program, additional insurance options are available through the Health Insurance Marketplace. Maryland Health Connection is the state’s official health insurance marketplace where you can compare and enroll in health insurance and access financial help to make coverage more affordable.
How Much Insurance Does Someone Need?
Each person is different and not everyone needs the same amount of insurance. The limiting factor for many people is the cost of the plan. But a person should make sure to get the most coverage for the money they spend.
Whether choosing insurance for the first time or evaluating a current plan here are some things to keep in mind:
Compare monthly premiums, deductibles, co-pays and/or co-insurance to make sure you are getting the best deal for your health insurance needs. Consider not just about how much you pay per month, but also how much money is needed to pay co-pays and co-insurance.
Make sure there is a broad range of mental health professionals included in the health plan’s network of providers. Some mental health professionals do not take insurance, so check to see what the insurance plan will pay for out of network providers.
If a person has found the right medication to treat their illness, they should find a plan that covers that medication to maintain wellness.
Some health plans place limits on the number of office visits for things like therapy. Choose a plan that allows the number of visits needed. Depending on a person’s need, they may need to consider differences in inpatient and outpatient coverage.
Federal law requires most health insurance plans to provide the same level of coverage for mental health and substance use conditions as they do for other medical conditions (this is called parity). Here are some warning signs that your plan may be violating parity:
- Your plan allows fewer visits for mental health care than for other types of health care.
- Your out-of-pocket costs for mental health care are higher than for other types of medical care.
- You have to call your health plan to get approval for mental health care, but not for other types of health care.
- Your health plan won’t pay for mental health treatment that your mental health provider says you need.
- You cannot find a mental health provider in your health plan network or you cannot get a timely appointment.
To learn more about what to do if your rights have been violated, click here.
Mental Health Insurance Parity
Mental health parity describes the equal treatment of mental health conditions and substance use disorders in insurance plans. When a plan has parity, it means that if you are provided unlimited doctor visits for a chronic condition like diabetes then they must offer unlimited visits for a mental health condition such as depression or schizophrenia.
However, parity doesn’t mean that you will get good mental health coverage. Comprehensive parity requires equal coverage, not necessarily “good” coverage. If the health insurance plan is very limited, then mental health coverage will be similarly limited even in a state with a strong parity law or in a plan that is subject to federal parity.
How to Know if a Plan Must Follow Parity
In 2008, Congress passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) to ensure equal coverage of treatment for mental illness and addiction. In November 2013, the federal government released rules to implement the law. Before this law, mental health treatment was typically covered at far lower levels in health insurance policies than physical illness.
Whether or not a plan is covered by federal parity law depends on the kind of health plan a person is enrolled in and even its size.
Below is a breakdown on what health plans do and do not have to follow parity:
Health plans that must follow federal parity include:
Health plans that do not have to follow federal parity include:
- Group health plans for employers with 51 or more employees.
- Most group health plans for employers with 50 or fewer employees unless they have been “grandfathered,” which means it was created before the federal parity laws went into effect.
- The Federal Employees Health Benefits Program.
- Medicaid Managed Care Plans (MCOs).
- State Children’s Health Insurance Programs (S-CHIP).
- Some state and local government health plans.
- Any health plans purchased through the Health Insurance Marketplaces.
- Most individual and group health plans purchased outside the Health Insurance Marketplaces unless “grandfathered.”
- Medicare (except for Medicare’s cost-sharing for outpatient mental health services do comply with parity).
- Medicaid fee-for-service plans.
- “Grandfathered” individual and group health plans that were created and purchased before March 23, 2010.
- Plans who received an exemption based on increase of costs related to parity.
If you are unsure about what type of plan you have, ask your insurance carrier or agent, your plan administrator, or your human resources department.
Benefits and Services That Must Be Covered Equally
If a plan has to follow federal parity law, then the following must be covered equally when it comes to treatment limits and payment amounts.
- Inpatient in-network and out-of-network
- Outpatient in-network and out-of-network
- Intensive outpatient services
- Partial hospitalization
- Residential treatment
- Emergency care
- Prescription drugs
- Co-pays
- Deductibles
- Maximum out-of-pocket limits
- Geographic location
- Facility type
- Provider reimbursement rates
- Clinical criteria used to approve or deny care
Federal parity also applies to clinical criteria used by health insurers to approve or deny mental health or substance use treatment. The standard for medical necessity determinations—whether the treatment or supplies are considered by the health plan to be reasonable, necessary, and/or appropriate—must be made available to any current or potential health plan member upon request. The reason for denials of coverage must also be made available upon request.
Signs a Health Plan May Be Violating Parity Requirements
- Higher costs or fewer visits for mental health services than for other kinds of health care.
- Having to call and get permission to get mental health care covered, but not for other types of health care.
- Getting denied mental health services because they were not considered “medically necessary,” but the plan does not answer a request for the medical necessity criteria they use.
- Inability to find any in-network mental health providers that are taking new patients, but can for other health care.
- The plan will not cover residential mental health or substance use treatment or intensive outpatient care, but they do for other health conditions.
If you think your plan has violated parity requirements, you can talk with your plan. The reason for denials of coverage must be made available by your insurance company upon request. If your treatment is denied and you disagree, you should contact your plan’s customer relations division right away. You may file a written formal appeal (ask your plan for details) or use NAMI’s template letters if your informal attempts are not successful.
