What Can You Do If Your Mental Health Benefits Are Denied?

Carol McDaid
Carol McDaid
Parity Implementation Coalition

Follow these practical steps to win your appeal.

CFYM Note: Last week, Carol McDaid answered the question, “Doesn’t health insurance have to cover mental health care?” She also described steps to make sure you’re getting all the health care benefits you should. This week, Ms. McDaid covers what the mental health parity law means for you when you don’t get the benefits you’re entitled to.

From promise to reality

The fact that we now have two federal laws requiring mental health parity is cause for celebration—both for those of us who spent years advocating for the laws and those of us, me included, who have been denied coverage by our insurance plans.

The Mental Health Parity and Addiction Equity Act was signed into law in 2008. The Affordable Care Act goes into effect January 1, 2014, and will require more plans, including those in the newly created health insurance exchanges, to offer mental health parity. (Read more about the laws in Part 1 of this series.)

The federal laws are on top of state laws that exist in approximately 40 states to protect people from being denied mental health benefits through public and/or private employer-sponsored health insurance. (View a chart of state mental health parity laws from the National Alliance on Mental Illness.)

Fight for your mental health insurance rights

Yet it is naïve for people to assume that a faucet will be turned on and mental health and addiction benefits will flow freely as a result of the laws. Just as advocates fought for legal protection of mental health benefits, we must now fight for obtaining the rights and the benefits themselves. And we do that by

  • appealing our denials
  • copying state and federal regulators on those complaints, and
  • demanding our legally protected fair treatment

This may seem a lofty and overwhelming task to someone struggling to manage mental health or addiction issues, or someone who is supporting a loved one with behavioral health needs. And it might be especially discouraging to those already weary from years of battling for mental health benefits.

However, the truth is there are very specific things you can do when denied coverage for mental health and addiction benefits. Yes, appealing a denial may require some effort; but we all deserve fair treatment, and we finally have the legal grounds to demand it.

Where to start

The Parity Toolkit for Addiction & Mental Health Consumers, Providers and Advocates created by the Parity Implementation Coalition, provides step-by-step advice for the appeals process, explains how the health reform law will change the appeals process, and offers tips for a successful appeal, including how to write an appeal letter and where to turn after you’ve exhausted your insurer’s internal review process.

The toolkit was based on people’s real-life experiences in fighting denied coverage. It draws from the most successful techniques and strategies, and it allows you to benefit from others’ hard-fought victories. For detailed information, read the Toolkit. See below for an overview of coverage denials to be on the lookout for.

What might be denied

The denials that you may encounter going forward are likely the same benefits that were denied in the past. The most common include:

  • Residential care for adolescents and adults
  • Partial hospitalization and intensive outpatient care for addiction
  • Care that exceeds 20 visits to an office-based clinician
  • Tests, services, or drugs that are not deemed “medically necessary”
  • Failure to secure preauthorization as required for every visit by a patient’s psychiatrist, psychologist, or social worker
  • Medication and treatment that fall under plans’ “fail-first” policies
  • Substance use care provided by a provider that also provides residential-treatment
  • Court-ordered treatment

So what should you do if you believe you have been unjustly denied coverage? Check back to this site on Thursday September 26 to review a step-by-step process for navigating the appeal process.

Your turn

We want to hear about your experience.
Have you ever been denied coverage for a mental health condition?
After January1, 2014 what steps will you be taking to ensure equal coverage under the law?

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