Know your insurance rights.
Some local NAMI members have been sharing that they are experiencing new difficulties in getting their insurance claims paid for psychiatric care. The new Mental Health Parity laws came into effect in 2014, so there are many changes to be sorted out, and NAMI members will be at the forefront of enforcement.
In 2014, the State of California followed the Federal government in making parity law related to mental health coverage required as a component of healthcare insurance law. As a result, mental health benefits can not have higher copays or restrictions than any physical health benefits. For example, many plans use to require 50 percent copays for mental health treatment and had very low treatment limits in terms of visits. Now, this can only be true if that is the plan’s rule for physical health care services as well. Most plans have no limits on outpatient care visits and fixed copays.
This legislation was an important step in the right direction, but there are still many difficult and unclear areas of the law and families may need legal or advocacy assistance particularly if the child or patient needs residential care or intensive case management. These two services do not have parallels in the physical health world and so working this through in advance with your primary care physician and psychiatrist with good documentation of medical necessity is recommended. Many health plans still use behavioral health carve out plans which means they do not directly manage the panel or providers to be sure it is adequate to meet local needs. Unless you are in a PPO where you can choose your providers and go out of the local network, you need to at least try to use the local clinical network first or ask your preferred clinician to consider joining the panel. PPOs do provide more flexibility but are often more expensive.
The denial of benefits does not mean that you should assume services will not be covered by your insurance plan. There are some good advocacy options if you feel your insurance provider is intentionally denying care or delaying payment to you or to the provider, in violation of the mental health parity law.
If you are in an HMO or PPO plan that is not self-insured, you can call the Help Line at the California Department of Managed Healthcare, or DMHC (see link for brochure on the right) for advice, and later, if your private insurance rejects your grievance, you may appeal to DMHC for an Independent Medical Review of your case. DMHC has the power to overturn decisions of private insurance plans.
Another good resource in California is the Mental Health Parity Project at Disability Rights California, which can provide guidance about your case (see link to the overview of their services on the right).
There are also more and more law groups specializing in health insurance law and legal issues. Often one strongly written letter from an attorney can get an issue resolved. In addition you can file a formal complaint with the Insurance Commissioner of California and let your plan know you have done this and will have representation for your claim. Having good documentation of medical necessity for the care is also a critical component and sometimes a second opinion helps.
Parity Implementation Coalition http://parityispersonal.org
Brochures from the California Coalition for Mental Health: