How-To Get the Most Out of Your Mental Health Coverage

Not everyone has an insurance policy that includes mental health coverage. But even people who do may be surprised by how difficult it is to use their mental health benefits. When you try to use insurance to cover mental health treatment, issues you may encounter include everything from not being able to find in-network therapists to having your mental health claims denied.

 Your insurance company wants you to think you have a great policy, but they don't want you to know they're fighting against your ability to use it. In March 2019, a federal court judge found that United Behavioral Health discriminated against people seeking mental health treatment by blocking or denying mental health claims, and they're not the only one doing it. Dirty tricks in insurers' playbooks include: 

1. Denying mental health claims as "medically unnecessary."
2. Limiting or restricting the number of therapy sessions you can claim.
3. Creating "ghost networks" that make it harder to find in-network therapists.
4. Shifting more costs to consumers through higher co-pays, premiums, and deductibles.

However, insurance companies don't have to be the only ones with tricks up their sleeves. You can be the Road Runner to their Wile E. Coyote. While they might have big wallets and crates of supplies at their disposal, you can outsmart them.

 If there's one thing insurers count on, it's that you won't fight back when they refuse to cover mental health claims. But not only can you fight back when claims are denied, you can proactively prevent insurance-related issues by knowing your policy and your rights. These five tricks will help you get the most out of your mental health benefits and win the battle of wits with your insurance company.

 1. Know your policy.

One weird thing insurance companies do is make it hard for you to find or use your policy documents. Even when they actually supply you with a hard copy of your policy with a clear index and Table of Contents, chances are you're not sure how to understand or use your policy booklet, and that it's not written in a way that makes it easy to figure out on your own.

 Your policy is your binding contract with your insurance company, so making sure you have a copy is a great first step in getting the most out of your insurance. It's even better if you can get a copy of both the full policy and an Explanation of Benefits (EOB) document, which provides a quick overview of the benefits in your policy. Log on to your insurance company's website to see if you can find digital copies of these documents. You can call your insurer's customer service number if you're having a hard time finding your policy booklet and EOB on your own.

 Once you have a copy of your policy, flip through it to see what you find. If you're not sure what certain terms or policy descriptions mean, you can find tips and guides online, like this set of tools from Healthcare.gov. You'll want to start by confirming that you have mental health benefits. Look for "mental health" in the index (if your plan has one) or do a text search on your computer using Control-F or Command-F. Once you do, see if you can find any exclusions, or types of mental health treatment that aren't covered by your policy. Also look for any lists and descriptions of covered mental health benefits. The more specific the list, the better.

 Even if you're not completely sure what everything in the mental health section of your policy means, knowing just a little can go a long way. Insurance companies overturn claim denials and pay claims when people show them that the policy language means they should have covered those claims. And even if you're not dealing with a denial, knowing what your insurance policy says it covers can empower you to seek covered care and submit claims for it.

2. Know your rights.

While we don't offer legal advice at OpenCounseling and encourage you to seek a lawyer if you need legal help, we do recommend that you learn what the law says about how your policy should work and what you have a right to expect from your insurance company. You don't have to be an expert to be able to use your knowledge of healthcare law to stand up for your rights.

These are the two most important healthcare laws to know when you're reviewing your plan:

• The 2008 Mental Health Parity and Addiction Equity Act (Parity Act)
• The 2010 Patient Protection and Affordable Care Act (ACA)

The Parity Act prohibits insurance plans that provide mental health benefits from limiting or restricting those mental health benefits more than they restrict medical benefits. This means if your plan doesn't restrict the number of visits you can make to medical specialists every year, it can't restrict the number of visits you can make to mental health specialists (i.e. the number of therapy sessions you can have) each year, either. It also means co-pays should be the same for the same levels of outpatient medical and mental health care.

The ACA extended the Parity Act to cover more types of insurance plans. It also required new plans to cover mental health care as one of ten "essential benefits," meaning that plans created after March 10, 2010, should include mental health benefits and should provide mental health care coverage that's comparable with the medical coverage provided in the plan.  

There are some exceptions, though. Plans that existed before March 10, 2010, and that were "grandfathered" in, are not required to comply with ACA requirements. Also, small businesses with less than 50 employees are also not required to provide coverage to their employees.

Knowing these regulations can help if you need to appeal a denied claim. It can also inform your choices when you sign up for or change employer-based insurance plans.

3. Fight back if your claims are denied.

One trick insurance companies use to get around the requirements of the ACA is to automatically deny certain kinds of mental health claims. On paper, they may not seem to impose additional limits or restrictions on mental health care, but in practice, they find more reasons to deny mental health claims for "lack of medical necessity."

This means that according to their criteria, you didn't need the care you received. They may say you need to try a lower level of care unsuccessfully before they would consider the level of care you received necessary—regardless of the opinion of the medical or mental health professional who determined you needed the level of care you received. Such practices were technically outlawed as "step therapy" by the Parity Act. Though these ongoing issues show that mental health parity has not yet been fully realized, both courts and individuals are continuing the fight.

One way you can fight back is by appealing a denied claim. To appeal, you need to make an argument and gather supporting evidence to show why the insurance company should have paid the claim. Your policy booklet should provide an outline of the appeal process. Most insurance companies start by having you submit an "internal appeal" directly to the insurance company. Certain types of appeals can also receive an external review from an independent review board. To learn more about how the appeal process works, you can read our full article about it here.

4. Consider using out-of-network coverage.

Of course, if you find the perfect therapist in your insurance network, that's the best option. But if you're having a hard time finding a therapist in your insurance network who's the right fit, or even finding any in-network therapists at all, you're not alone.

Insurance companies may be intentionally restricting their networks to limit the amount of in-network mental health care available to consumers. It's not always the insurance company, though. There simply may not be enough mental health workers where you live, especially if you live in a rural area. The mental health workforce shortage is a growing issue across the country.

To make matters even more difficult, the number of insurance plans offering out-of-network coverage has been shrinking, especially in the individual market. So if you're lucky enough to have a plan with out-of-network benefits, consider using them If you can't find an in-network provider. Insurers that cover out-of-network care usually charge higher co-insurance or co-pays for out-of-network providers, so you'll pay more to see one, but less than you'd pay on your own if you were paying completely out of pocket.

For out-of-network claims, you usually have to pay your therapist the total amount they bill for a session at the time the bill is due, then submit the bills or claims to your insurance company for reimbursement. You'll need to check with your therapist if they're willing to help you with your out-of-network claims if your insurance company requires paperwork from them. If you want to cover your care with out-of-network benefits, it's important to talk to your insurance company and your therapist first to confirm that you can.

5. If all else fails, ditch your insurance.

Just because you have insurance doesn't mean you have to use it. There are good reasons to consider paying out of pocket for therapy:

• You need a specific type of therapy, and can find it in your area, but not from anyone who accepts your insurance.
• You don't have out-of-network benefits and all of the in-network therapists in your area have long waiting lists.
• You've found a therapist who's a perfect match. They don't take your insurance, but you can afford their sliding-scale rates.

If you can find a therapist who's a good match, who can schedule you for an appointment soon, and who charges rates that fit your budget, it may not be worth the wait or hassle of using your insurance for therapy.

Also consider any special resources you may have where you live. If you live near the campus of a university or college with a counseling department, they may offer free sessions to people willing to meet with a student therapist. You may also have a free or low-cost mental health clinic near you, be eligible for treatment through the public mental health system, or be able to get both medical and mental health care through an integrated clinic. For more ideas, you can read some of our past articles on how to choose the right therapist for your needs and budget:

• How to Choose a Therapist
• How Much Does Therapy Cost?
• Deciding How and What to Pay for Therapy
• Sliding-Scale Therapy: What It Is and How to Get It
• When Is It Worth It to Spend More on Counseling?

At OpenCounseling, it's our mission to help you learn more about the different ways you can meet your mental health needs. Our mental health system needs work, and gaps in care affect all of us. However, there are more mental health resources available than most of us know about, and we want to help you know all of your options so you can find the one that's best for you. If you can't find the right therapist in your insurance network, don't stop trying. You may be able to get your insurer to cover another therapist or may be able to find another affordable option. The care you need may be closer than you think.

Posted on 01/05/2020 by Stephanie Hairston, MSW

Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a masters-level clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments. She has also worked as a technical writer for a medical software company and as an editor for a company that appeals denials of insurance coverage for behavioral health treatment. As a writer, she is motivated by the same desire to help others that brought her into the field of social work and believes that knowledge is one of the most essential recovery tools. She strongly believes in the mission of OpenCounseling and in making therapy accessible for everyone.