Mental Health and Insurance Fact Sheet
October 25, 2019
Mental Health and Insurance Fact Sheet
For a person living with depression or bipolar disorder (a “mood disorder”), having insurance coverage can make the difference between receiving mental health care and being left untreated with potentially worsening symptoms, a condition that becomes harder to treat, and consequences in interpersonal relationships, at work, and all aspects of life.
As a caregiver to a person living with a mood disorder, you may need to support them in choosing a health plan, paying for it, finding providers that accept it, and advocating for benefits, sometimes even challenging the insurance company’s decisions about treatment.
The more you know about mental health care, insurance, and patients’ rights, the better you will be able to assist your loved one in getting the care they need to get well.
PAYING FOR MENTAL HEALTH CARE
The costs of a person’s mental health care are typically paid by one or a combination of these:
- Private insurance. Includes employer-sponsored coverage (for current employees or through COBRA after job termination) and health plans purchased through (or outside of) the Marketplace.
- Government-funded insurance. Includes Medicare, Medicaid, and CHIP for children and, in some states, pregnant women.
- Self-pay. Paying for care from your own resources without insurance, whether due to your not having insurance or to a lack of providers who take your, or any, insurance.
AFFORDABLE CARE ACT (ACA) PLANS
The ACA requires that iindividual, family, and group health insurance plans offered through the Health Insurance Marketplace meet these criteria, among others:
- must cover 10 Essential Health Benefits, including mental health care
- must cover pre-existing mental health conditions and may not charge more for that coverage
- may not impose insurance company spending limits on mental health care
ACA-compliant plans cannot exclude mental health care from coverage. Mental health parity means that mental health care coverage cannot be more restrictive than physical health care coverage.
SHOPPING FOR A HEALTH PLAN
Choosing a health plan requires investigation and estimation. Because none of us can predict the future, we can’t be certain what our health care needs are going to be over the coming year. But we can account for treatment of chronic conditions that require maintenance (e.g., high blood pressure). We can think about our family’s current medical and mental health conditions and make assumptions about which might need treatment and how intense that treatment may be (e.g., does it require hospitalization). In making your estimates, be realistic or, if you want to be more conservative, consider “worst-case scenario” for care and expenses.
QUESTIONS TO CONSIDER AS YOU REVIEW HEALTH PLANS
- What are the expected mental and physical health care costs for the coming year for all members of your family who will be on the health plan?
- Do your preferred providers participate in the insurance plan, so they are “in-network?”
- What are the charges for current medications? Must they be ordered from a pharmacy specified by the insurance company?
- When is prior authorization required, particularly for mental health care?
- Are services at your hospitals and facilities charged at a higher rate than other nearby providers because of a tiered provider system?
- What level of monthly premium payment does your cash flow allow?
- Are you eligible for tax credits or subsidy?
WAYS TO ENROLL IN. A MARKETPLACE HEALTH PLAN
The federal government accepts health plan enrollment in several ways:
- Online at HealthCare.gov
- By phone via the Marketplace Call Center
- By completing and mailing a paper application
- With an agent, broker, or assister
- Through a certified enrollment partner’s website.
Most states have people who are trained to help with applying for and enrolling in coverage. Some enrollment assisters can help evaluate plans based on a family’s needs. Visit https://localhelp.healthcare.gov/
CHALLENGING AN INSURER’S DECISION
Each person covered by an ACA-compliant plan has the right to
- information about why a claim or coverage was denied
- appeal to the insurance company (internal appeal)
- an independent review of the decision (external review)
- continuing coverage of ongoing treatment during internal appeal without financial liability (and during external review if person is a danger to themselves or others)
WHEN YOU SEEK REVIEW OF AN INSURANCE COMPANY’S DECISION
- Meet all deadlines and submit all forms and documentation required by the plan
- Document all calls, correspondence, and notices
- Request all notes from the insurance company about its decision-making
- Ask your loved one’s provider for support to reverse the decision (e.g., letter to insurance company, scientific articles)
- Consider getting advice from a professional, such as a lawyer or consumer advocate.