The Affordable Care Act, also known as the ACA, mandates insurance coverage for mental health and substance use disorders. These illnesses are designated as essential health benefits under the ACA. This means public and private health insurance plans are required to cover mental health and substance use disorders and insurers may not deny coverage for these conditions. In addition, these benefits must be comparable to medical and surgical benefits under the same plan. This is known as parity. Another key provision is young adults up to age 26 can obtain coverage under a parent’s insurance plan.
Accessing Benefits for Mental Health Substance Use Disorders
A recommended first step to accessing benefits is to contact the insurer and request specific plan benefits. As we know from experience, this can be time consuming and somewhat confusing as insurance terminology varies across the industry. Here is a quick list of interchangeable words which may be helpful when accessing a phone menu of options or speaking with a representative:
Behavioral health, mental health, psychotherapy, counseling
Substance use disorders (ACA term), addiction, substance abuse, chemical dependency
In-patient facility treatment, residential facility treatment (not a medical hospital)
Intensive outpatient treatment, IOP (typically meets 3 times/week)
Outpatient treatment, continuing care (typically meets 1 time/week)
The insurance company will identify in–network and out-of-network benefits pursuant to a specific plan. In-network providers have contractual payment agreements with that insurance company. The out-of-pocket expense to the insured person is much less for in-network providers, such as a minimal co-payment. While plan-specific, a typical range of in-network coverage paid for by the insurance company is 70 percent to 100 percent. It is important to request a list of in-network providers from the insurance company as this is a good place to begin searching for services.
Out-of-network providers are not contracted with an insurance company and the out-of-pocket expense to the insured person is much greater. The typical range of out-of-network coverage paid for by an insurance company is 40 percent to 60 percent. The insurance company will not have a list of out-of-network providers; the insured person generally selects a provider of his/her choice and will likely have to advance the funds for treatment before seeking any available partial reimbursement.
Pre-authorization requirements may be a component of accessing benefits. Be sure to identify if pre-authorization is needed, and obtained, before seeing a provider as failure to do so may result in denial of a claim. If there are limits to a plan, such as number of visits or laboratory tests, the pre-authorization process will typically identify what those limitations may be.
Appealing Insurance Company Decisions
The ACA contains provisions for how to appeal denial of benefits by insurance companies. The process is conducted through a third-party independent reviewer, can be complex, and is usually triggered after all other efforts to resolve issues between you and your insurance company have failed. It is important to check the time limitations in your policy. That being said, before commencing the appeal process, we highly recommend contacting your state’s Office of the Insurance Commissioner as we have found agency personnel to not only be well-versed on the complexities of the ACA, but offer valuable consumer advice and resources.
Washington State Office of the Insurance Commissioner, www.insurance.wa.gov
Talk to an insurance expert – (800) 562-6900