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What to Know If You’re Confused About Mental Health Insurance Coverage

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Editor's Note

Any medical information included is based on a personal experience. For questions or concerns regarding health, please consult a doctor or medical professional.

Mental health encompasses our cognitive, behavioral and emotional well-being. In simple terms, it deals with how we think, act and feel. If any of these factors are affected, one may not be able to function well in the community. This is because mental health is as equally important as our physical health.

According to the data gathered by the Substance Abuse and Mental Health Services Administration, “nearly one in five Americans had a mental illness in the past year.” And this may comprise more than 20% of American adults annually. It also ranges from an anxiety disorder to a personality disorder. Treatment for these mental illnesses includes medications and psychotherapy.

What You Need to Know About Insurance Coverage

In the past, the focus of many health insurance companies is better coverage for physical illnesses. However, in 2008, Congress has passed the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act — which also commonly known as the Mental Health Parity Act or Federal Parity Law — requiring insurance companies to also cover services for mental health, behavioral health and substance abuse disorders.

The Mental Health Parity Act requires insurance companies to treat financial requirements for both physical and mental health equally. This means you will not be paying more for your mental health sessions than what you normally pay for with your appointments to your medical doctors. It also covers non-financial treatment limits such that it suppresses insurance companies to put a firm limit on how many mental health visits per year.

However, it does not prohibit insurance companies from implementing limits related to medical necessity. The insurance companies are allowed to assess your case to see whether additional treatment is really necessary according to their own criteria.

Take note that psychologists and other mental health providers have the option to choose whether or not to accept your insurance. The major factor for this is because, despite the Federal Parity Law, many insurance companies are still not compliant with their reimbursements and so many mental health professionals refused to participate in their arrangements.

If you have concerns, you may ask your human resources department (if presently employed) or, better yet, get in touch with your insurance company directly. If you still have unanswered questions or you wish to file a complaint, you may visit the U.S. Department of Health and Human Services which can help you find the appropriate agency that can assist you. You may also visit the Parity Track website where you can obtain information about the law and you may even file a complaint with them about your experience.

Checking If Your Health Insurance Plan Covers Mental Health

Reviewing the details of your enrollment materials will help you check the coverage levels for all the benefits of your health insurance plan. If you are still uncertain, try contacting your insurance company directly.

If you have been denied coverage by your insurance company or reached a limit on your plan, you may also check your Medicaid plan. An array of mental health services and substance use disorder services are offered to all state Medicaid plans. Some of these services offered by Medicaid are, among others, therapy, medication management and counseling.

Insurance Coverage for Speech Therapy and Occupational Therapy

Many patients with mental illness will be needing the help of a speech pathologist and/or occupational therapist. Unfortunately, not all insurance companies cover for such mental health services while some explicitly specify exclusions to such services.

Insurance companies are driven by financial priorities and they control the cost at the service delivery level. They often define the scope of speech and occupational therapy by identifying what type of services they will pay for.

And currently, I’ve found most health insurance companies have very limited coverage for speech or occupational therapy. There are some insurance policies that exclude children with congenital conditions, and it is so regardless of the severity, especially those with autism or developmental delays. Many major insurance companies only cover for speech and occupational therapy for non-chronic conditions or those which resulted only from diagnosed medical illness, accidents or surgery.

Moreover, most of these insurance companies only cover short-term rehabilitation services for conditions that are expected to show significant improvement after several sessions. Many insurance companies also set limits on the number of sessions such as only 20 to 30 visits per year.

It is also very important to know that many insurers count all types of therapy (speech, physical, behavioral or occupational) toward this limit, so be sure to check with your insurance company if you are receiving other types of therapy.

Additionally, it is crucial to ask your insurance company what documentation is necessary to get covered. Some of them will require a written prescription from the doctor and interview certification from the speech pathologist or occupational therapist. When inquiring about your coverage, ask specifically about diagnostic procedure codes your therapist should use to accurately reflect the coverage you have.

Lastly, if you have any complaints about your speech or occupational therapy coverage, always ask for the written denial of your reimbursement and try to appeal properly in your insurance company or to your state’s insurance commission.

Photo by Christopher Sardegna on Unsplash

Originally published: November 21, 2019
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