Navigating the sometimes-complicated pathways to get to the right care for a child experiencing mental health issues can be frustrating. Once you do find the care your child needs, the inevitable next question is about costs and affordability. How does the average family afford the care their child needs?
Is mental health treatment covered by insurance?
Historically, American families have relied heavily on private health insurance – predominantly employer-sponsored policies -- to afford medical care and treatment. However, those same families who needed mental health care and treatment often bore the total burden of the cost. The health insurance companies did not provide equitable benefits for mental health treatment as they did for medical care. In 2008, Congress passed a law to ensure parity, meaning equal coverage and benefits for mental health care, and in 2013 released rules for implementing that law. In short, if a health care plan covers unlimited doctor visits for a chronic physical illness such as diabetes, that plan must also cover unlimited visits for chronic mental illness.
However, not all health plans have to follow federal guidelines for parity. This includes have: 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; and plans that received an exemption based on increase of costs related to parity. If you are unsure about the type of plan you have, talk to your company’s benefits advisor or call the health plan’s customer service line directly.
Check your benefits
Even if an insurance plan is required to provide parity for mental health care, there can be many variables among insurance policies when it comes to co-pays, out-of-pocket expenses, and lifetime maximums. Check that the provider you want actually taking insurance and covered by your plan. Here is a list of some of the questions you should ask your insurance provider:
- Confirm that the “in-network” providers are taking new patients
- Are there limits of services imposed by your insurance (number of sessions, number of inpatient or partial days)?
- What does your insurance plan consider medically necessary and, if you need pre-approval for coverage, what are those guidelines?
- What is your share of costs based on deductible and the type of service provided?
For those families who do not have private or employer-sponsored insurance, accessing affordable mental health typically requires government-funded subsidies to help defray out-of-pocket costs. Programs such as Medicaid and the Youth Empowerment Services (YES) Waiver can cover a large portion of the costs of mental health treatment, which is a significant benefit to families. Unfortunately, fewer care providers are accepting patients with Medicaid as the fee reimbursement for the provider is often much lower than that of private insurance. This can make finding a provider for your child or it can take longer to get an appointment with mental health provider for a child.
What to Do if You Are Denied Parity
The good news is that the Texas Legislation just passed HB10, a bill that will help make sure that insurance companies in Texas truly respect the parity law in two ways: by increasing the Texas Department of Insurance’s authority to enforce the existing parity law, and creating a position specialized in resolving issues families may encounter when seeking access to behavioral care. While the new law won’t likely go into effect until September of 2017 and details of how TDI will enforce these laws are still unclear, there are some steps you can take to be an advocate for a child in your care.
The National Alliance on Mental Illness (NAMI) provides this valuable list of signs that your insurance company has violated parity requirements. . They include:
- 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 abuse treatment or intensive outpatient care, but they do for other health conditions.
If you think the insurance company providing your plan has violated parity requirements, your first step is to contact your insurance provider. Their reason for denials of coverage must be made available 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) if your informal attempts are not successful.
Other Affordable Care Options
There are affordable mental health care resources outside the traditional framework, many of which US News and World Report outlined in a 2009 article. Depending upon your family’s circumstances, these may be practical options.
- Mental Health America, an advocacy organization with over 300 affiliates in 41 states, works with people to connect them with affordable mental-health services in their communities. Click on "local MHAs" ontheir homepageto find services in your area.
- Community health centers. In addition to primary-care services offered in thousands of locations across the country, they are increasingly offering mental-health services. Fees are charged on a sliding scale based on income. Find a center in your areahere.
- Community mental-health centers.These centers serve Medicaid and other low-income patients. State income limits vary. Click on "find a provider"here, and call to find out whether you may qualify.
- Employee Assistance Programs.Many employers offer a limited number of counseling sessions and referrals to mental-health professionals through an EAP service. For some people, this may be all they need.
- Churches, synagogues, and other places of worship.Although they are not licensed therapists, clergy members are trained in counseling, and their services are generally free.
- Group therapy.Many therapists offer group sessions, which can be a less- expensive alternative to traditional one-on-one counseling. You can find a psychologist in your areahere through the American Psychological Association.
Other options: online cognitive behavioral therapy (CBT) services can be lower costs and help for some conditions such as anxiety and depression.
Partners in Advocacy
Navigating medical insurance can be time-consuming and frustrating. But remember, while you are always the best advocate for your family, support is available and you are not alone. Enlist your local chapter of NAMI or the National Federation of Families for Children’s Mental Health (FFCMH), both of which can provide support, guidance and encouragement.
With an eye to the best for our kids,
Michele Autenrieth Brown is the director of development for Clarity Child Guidance Center. She became passionate mental health advocate after trying to navigate the system of care to support a family member. When she is not shuttling kids to practices or spending time with her husband, Michele is perfecting just what to say to get the perfect eye roll and sigh from her teen and pre-teen children.
If you are experiencing an emergency, please call 9-1-1. If you need help locating mental health resources in your area, visit the Bexar County Community Resource website, call your local health department or the National Alliance Mental Illness's helpline at 800-950- NAMI (6264).