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Health insurance coverage is vital for millions of Americans. Yet, some people are still not sure what their insurance plans actually cover? This is especially true for behavioral or mental health treatments. Here is a general summary of insurance coverage for mental health treatments.

Mental Health Counseling and Medicare:

For older patients, through the CMS, Medicare Part B individuals receive medical insurance. Medicare Part B does include coverage and can help pay for outpatient mental health services. Some of the details of this coverage include:

  • One depression screening a year for individuals covered under Medicare Part B. However, the depression screening must be performed in a primary care physician’s office or primary care clinic that is able to provide follow-up treatment and referrals.
  • Psychiatric evaluations, diagnostic tests and medication management.
  • Individual and group psychotherapy with doctors or certain other licensed professional healthcare providers.
  • Family counseling, if the main purpose is to help with the Medicare beneficiary’s treatment.
  • Some prescription medication that is not usually self-administered.
  • Inclusion in PHP otherwise known as Partial hospitalization.

Other Insurance Coverage for Mental Health Care:

In recent years, there has been a tremendous change in how insurance companies cover mental health treatments. In previous years, when people visited their primary care doctor, insurance payers might have covered 80 percent of the cost. But, when people visited a psychiatrist (or similar behavioral health provider), insurance payers may have only covered 50 percent of the medical cost.

However, in 2010, the laws surrounding private insurance plan coverage for mental health and substance use services changed. New laws now require that if a private insurance plan offers coverage for mental health services, it must be equal to the rest of the plan’s physical & medical health services.

This means that a person’s healthcare benefits must have equal treatment limits. Examples of this are the number of days people can stay in a hospital or how often they receive treatments. These newer laws also include parity in coverage for the following:

  • Co-insurance (percentage of costs of a covered health care service that a person pays).
  • Out-of-pocket maximums (the total amount you have to pay).
  • Co-payments (a fixed amount you pay for a health care service).
  • Deductibles (the amount that people have to spend before their insurance company starts to pay).

But there are some exceptions to these new coverage rules. One large exception is the fact that the new law does not apply to companies with 50 or fewer employees. This means that the insurance plans available to these workers do not have to provide parity or equal coverage for mental and physical health services.

In addition, federal laws do not require insurance plans to provide coverage for behavioral health treatments. It only means that if mental health insurance coverage is offered, then the law states that the coverage is equal with coverage for other health conditions.

Denied Insurance Coverage for Mental Health:

The website for the National Alliance on Mental Illness (NAMI) provides some advice on what to do in cases of denied behavioral health insurance coverage. Denials can occur for mental illness treatments due to a number of reasons. There are a variety of methods that determine whether a type of treatment is considered medically necessary or is covered by that particular insurance plan.

People have the right to appeal an insurance company’s decision in regard to issues of coverage. Two very common terms that insurance companies use when processing a denied treatment or therapy are:

  • Medical Necessity:  Often used by insurance plans to decide whether treatments or health care supplies recommended by a mental health provider is reasonable, necessary and appropriate.
  • Prior authorization (prior approval):  Is a type of utilization review that is used when healthcare providers must ask for approval before insurance health plans will agree to pay for a medical service or prescription drug.

If people feel that they have been denied insurance coverage, they can file an appeal. Insurance plans have an internal and external review process. If people are not satisfied with these outcomes, they can contact their state’s insurance division for help.

The Center for Medicaid and Medicare Services (CMS) can also offer assistance. If individuals feel that the insurance companies in their state are not obeying the parity laws, they can contact the CMS Help site.

Final Details:

For more specific answers, individuals should directly contact their insurance provider. For specific questions about behavioral health coverage in the state of Ohio, people can also directly contact Emerald Psychiatry & TMS Center. Their center is in-network with a large number of major insurance providers. Specific coverage details vary based on an individual plan and policies of the various companies. Whether a person has coverage through Cigna, BCBS or UHC; their experienced and friendly staff can help clarify insurance plan coverage questions.

To contact them through email, please click HERE. To call them directly their main office phone is 614-580-6917. Emerald Psychiatry & TMS Center provides experienced and effective behavioral health services in central Ohio.

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Contributor:  ABCS RCM

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