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?

Facebook Comments

12 comments
Rawtruth
Rawtruth

I live in Washington State and my health insurance denies my doctors request every 6-8 weeks for weekly psychotherapy. He currently has to fill out a 2 page form with qualitative goals (will shower 5 days this week). My most recent denial states "does not provide explicit treatment goals that would define your progress in treatment (e.g. specific, measurable goal that would indicate progress toward completion of treatment)". How I long for that magic pill that will end the mental illness battle. 

KentClark1
KentClark1

I'm happy that mental illnesses are now covered by a lot of policies. People have to realize that your mental health is just as important as your physical health. In fact, it can have an impact on your physical health. I don't see why it shouldn't be held in the same regard as the physical illnesses. http://www.baileymt.com/services 

pauldavid6866
pauldavid6866

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JanArcher
JanArcher

My patients are being denied treatment.  because "optim" decided I did not respond to a request for "infrmation" two dates of service notes on time.  Plus, the patient has been told that two yers of theray for PYSD was enough, and they would only authorize her monthly sessions, but, they would not pay for them.!!

JanArcher
JanArcher

I am a provider.  Optum has decided to Pre approve paymetn.  I see the patient, then I send the recodesand codes, if Optun decides the care was not necessary I woill not get paid.  I am already being denied payment becaue they supposedly attemptd to contact me twice and (I was on vacation out of state) coudl not "get ahold of me, and I did not respond !!  My answering service clearly said, the office is closed until ... then if this is urgent call .... I left a phone number.  then I received a letter asking for copies of records for two specific ates of service.it would be due in 45 days.  there was NO mention of consequences.   I then receive a letter saying I will not be paid for that apatient , (the onesthey requested information of ) becuse I did not submitt the requested information.  I have a rule here, I will not release a rcored with out letting the patient read what I am sending  Menta heath records are very sessitive.  Not like a clear diabeties etc.  I then saw the client, I submitted her two dates of service notes.  I and the patient both received a letter stting that her diagnosis was PYSD and shedid not need weekly treatment, theyh would only authorize every four weeks session, plu they would not pay me because i did not submit the records on time, plus, she can see me if she wants , but i can only charge her the copay.  


So many good season psychiartists have closed their pract UBH is denying payment    I never heard of pre authoriqing payment, it was not in my contract, I am suppose to submit an appeal.  I know it will be denied.  what should I do ?

sonoma
sonoma

our daughter is in a residential treatment facility for substance abuse, alcohol abuse, depression, suicide ideation and self harm.  United Behavioral Health paid for 20 days but has refused to pay for anymore treatment. We are currently paying for her residential stay for the last 3 months.  We filed a Specialty review where it would be reviewed by an outside source to get a determination and that was also denied.  What would be my next step????

Ruggles
Ruggles

Good article about Mental Health Benefits Are Denied.thanks for this article !

jackrican
jackrican

My wife has been denied treatment from our insurance company,  She has various mental disorders ranging from BPD to others.  It seems that most insurance companies outsource their Mental Health Benefits to companies like New Directions.  New Directions take a stance that will always deny in-patient services unless the patient bruises or cuts themselves causing bodily harm.  In my situation, I prevented my wife from doing this by restraining her and taking her to the hospital and in turn, she was denied because there were no visible marks.  This sends the wrong message as she needs the help..  Is the message to sit back and let her harm herself?

JanArcher
JanArcher

@jackrican I have patients that had substnce abuse issues, ; they were told they had to appear at the inpatient site "drunk" and then tey could get admitted.  !!  this is parity ??