One in six children have mental, behavioral or developmental disorders. Without the proper treatment, the symptoms of various mental health conditions can have severe implications on a person’s life.
Through mental health parity, a person can receive the care they need to improve their quality of life. Learn what mental health parity is, how it can help you obtain necessary care for your child and how you can appeal to your insurance company so they cover treatment costs.
In This Article
- What Is Mental Health Parity?
- What Is a Medical Necessity?
- Other Terms You Should Know
- Types of Care That Are Commonly Denied
- The Mental Health Parity Act in Georgia
- How to File a Mental Health Parity Claim in Georgia
- How Parents Can File a Complaint With the Georgia Office of Insurance and Safety
- Seek Mental Health Care at Hillside®
What Is Mental Health Parity?
Mental health parity is a concept that requires insurance companies to offer equal coverage for substance use disorders and mental health needs. If your insurance provider offers a plan with parity that includes unlimited doctors visits for conditions such as diabetes, your child can receive the same level of treatment for mental health conditions such as depression or anxiety.
To know if your insurance plan includes mental health parity, consider if it’s a:
- Group health plan from an employer with a staff of 51 or more
- Group health plan from an employer with a staff of 50 or fewer, unless it’s been “grandfathered” in, or made before parity laws
- Plan you purchased through the Health Insurance Marketplace
- Group or individual health plan obtained outside of the Health Insurance Marketplace, unless it’s been “grandfathered” in
- State Children’s Health Insurance Program (S-CHIP)
- Medicaid Managed Care Plan (MCOs)
- Plan from the Federal Employees Health Benefits Program
Mental health parity doesn’t mean you’ll receive good coverage for mental health conditions, just what insurance companies consider equal coverage. If your chosen plan only offers limited treatment for physical ailments, your mental health care will also be limited.
What Is a Medical Necessity?
Medical necessity refers to the criteria used by insurance companies to determine if your mental health care provider’s treatments and health care supplies are necessary to your treatment. If your insurance provider determines the treatment prescribed by the mental health care professional is essential to your health, it can be covered under your insurance.
Your insurance provider will outline medically necessary treatments in their policies. Treatments that aren’t covered will have to be paid for out of pocket. Certain states may have various laws on what’s considered medically necessary, so it’s essential to conduct thorough research to determine what treatments will be covered. In some cases, your doctor may be asked to provide a “Letter of Medical Necessity” to your provider to authorize coverage for your medical treatments.
Other Terms You Should Know
When you’re seeking care for your child and get denied, it can be frustrating, mainly due to insurance providers’ terminology. A few other terms you should be aware of include:
- Utilization review: This is a process that insurance providers use to determine if treatment is medically necessary and in line with accepted medical practices. If treatment is in line with medical practices, that means that it’s backed by evidence-based research and proven to be effective at treating specific medical conditions.
- Prior authorization: Prior authorization is also known as pre-approval. It requires your medical provider to seek approval from your insurance provider before moving forward with treatment. Prior authorization may also be required for prescription medication.
- Step therapy: Step therapy is a type of authorization where patients are required to start with a less expensive drug or treatment method before moving to a more expensive option.
Types of Care That Are Commonly Denied
When seeking care, you might notice that certain treatments are denied more often than others. If you’re denied coverage for certain mental health services for your child but think they are medically necessary, you can appeal to your insurance provider. Types of care that are often denied include:
- Residential mental health treatment: If you’re looking to have your child stay at a residential treatment center or hospital for mental health care, you may be denied care by your insurance company and asked to pay for treatment out of pocket.
- Intermediate levels of care: Some people seek mental health treatment at an outpatient or rehabilitation center, which insurance providers don’t always cover.
- Office-based diagnoses and treatments: Insurance providers sometimes deny certain diagnostic treatments and standardized tests that measure conditions such as depression. In some cases, psychotherapy services can also be denied.
The Mental Health Parity Act in Georgia
In 2008, the United States passed the Mental Health Parity and Addiction Equity Act (MHPAEA), which requires that insurance companies provide mental health care equal to the level of medical or surgical care offered for other conditions. In 2018, Georgia was graded with a 60 out of a potential 100, earning a D for its implementation of mental health parity.
Currently, nonprofit state and national programs are working with state lawmakers to enforce parity for people using both private and public health insurance providers. These programs are also working diligently to educate the public on the importance of parity in health insurance policies.
At the start of 2022, Georgia lawmakers introduced the Mental Health Parity Act to require all insurance providers in Georgia to offer the same level of treatment for mental health conditions as physical conditions. Currently, Georgians experience difficulty seeking treatment for mental health conditions and substance use disorders due to a lack of access to care. Their insurance may charge them more for care or require that treatment be paid for out of pocket. Lack of coverage can also increase the current stigma surrounding mental health conditions.
The hope is that this bill would reduce the out-of-pocket costs for individuals and family members seeking mental health care, reduce waiting times and allow people to receive the treatment they need.
How to File a Mental Health Parity Claim in Georgia
If you’re in Georgia and have sought treatment for mental health conditions for your child, you may have initially been denied treatment despite federal law requiring insurance companies to provide an equal level of care. You or your mental health care provider can appeal your insurance company’s decision, so your child can potentially receive the care they need. Appeal strategies you can use include:
- Analyze insurance company’s denial data: Use the data available to determine why the insurance company denied your care. You’ll be better equipped to navigate the appeal process with this knowledge.
- Develop an understanding of your insurance company’s utilization criteria: Your insurance company’s utilization criteria are used to determine what treatments are medically necessary. The better you understand these criteria, the easier it will be to make adjustments during the appeal process.
- Modify the language in your appeal: Sometimes, an insurance company can deny coverage because the language used doesn’t match their utilization criteria. When you’re making your appeal, provide enough detail so the insurance company can understand the connection between your condition and the care requested. Also, cite the need for the care you’re requesting, using information that proves how the treatment will help improve your condition.
- Continue to try: Insurance companies will often offer multiple levels for appeals, and it may take a few attempts to be successful. Take advantage of these opportunities to demonstrate the need for the level of care you’re requesting and continue to appeal for your mental health.
How Parents Can File a Complaint With the Georgia Office of Insurance and Safety
If you have an insurance plan and have been denied care for your child’s mental health, you might want to file a complaint about your insurance or how your provider handles your claim. If you’ve tried reaching out to your insurance provider and cannot solve your dispute, you can file a consumer insurance complaint with the Consumer Services Division of the Office of the Insurance and Safety Fire Commissioner.
Contact the Consumer Services Division before filing a complaint, where Complaints Analysts will answer your questions and help you decide what to do next. If you decide to file a complaint, follow these steps:
- Collect the necessary information: The Consumer Services Division will need specific information to assist you with your case. This information includes your name, insurance company, policy number, a description of your problem and all other supporting documents.
- File your complaint: Once you’ve collected the necessary information, you can officially file your complaint. You can either choose to submit a form or file your claim through the Online Consumer Complaint Portal. Choosing the online option is the quickest way to process your complaint.
- Take the next steps: With your complaint filed, the Consumer Services Division will send you an acknowledgment letter confirming that your complaint was received. They may also send a copy of your complaint to your insurance company, requesting a response if applicable. The Consumer Services Division may then conduct an investigation, and once that’s complete, they’ll reach out to let you know if your claim was resolved or if corrective action is necessary from your insurance company.
In some cases, you might disagree with the response to your complaint. In these situations, you can send a rebuttal to your Complaints Analyst, who will send the rebuttal to your insurance company. The Complaints Analyst will then reach out to you once they receive a response from your insurance provider.
Seek Mental Health Care at Hillside®
If your child has a mental health condition and is seeking treatment, you can file a mental health parity claim by contacting your insurance provider to submit an appeal. Taking care of mental health is essential to improving your child’s quality of life and coping skills. At Hillside®, we offer mental health treatment to children and young adults in Georgia needing residential or outpatient care.
We address mental health conditions to resolve family dysfunction and help children and teens navigate life. Our individualized treatments can help families improve their relationships and educate family members on how to navigate mental health challenges. Contact us today to learn more about how we can help your family.