How to Maximize Mental Health Coverage

Michael O. Schroeder

As Congress seeks to reach consensus on mental health reform, critics say deficits in insurance coverage often leave individuals and families struggling to afford therapy and medications to treat psychological issues, or worse: forgoing care altogether.

No overarching remedy exists to alleviate widespread impediments to access, rooted in everything from health plans that don't cover many mental health providers to higher out-of-pocket costs for some drugs that treat mental health conditions. Still, there are situation-specific strategies that may maximize coverage and make mental health services and medications more affordable. Here are a few, highlighted by health insurance brokers and experts at the National Alliance on Mental Illness, or NAMI, a grass roots advocacy, education and support organization.

Do Your Homework Before Enrolling in a Plan

With the next open enrollment period under Obamacare set to begin Nov. 1, it's a good time to get an early start researching health insurance plans. That's a solid idea whether you're getting a plan through a health insurance exchange or looking at several options an employer offers.

Large employer plans are not required to cover mental health services, but if they do offer mental health benefits, they must be on par or equivalent to benefits for general medical care, says Sita Diehl, director of state policy and advocacy for NAMI. "So the first thing to do if you're shopping for a plan through your employer is to make sure that mental health benefits are covered. Most are -- most plans do cover mental health -- but you've got to check it out," Diehl says. Those who work for a company that offers a plan that doesn't cover mental health may choose to purchase insurance outside their company. You may end up spending more of your own money on monthly premiums as a result, however.

If you're already seeing a mental health provider for therapy or medication management, make sure he or she is in your plan's network. "The provider networks are nowhere near as extensive" for mental health as for clinicians who treat physical issues, Diehl says. "So it's harder to find someone in your health plan's network." But experts say enrolling in a plan that covers the providers you see and the medications you take can make a substantial difference in what you pay out of pocket. For many, that can affect whether they're able to afford needed mental health treatment. For those getting a plan through health insurance exchanges, go to healthcare.gov. "You do have to [dig] down deep, but you can see whether your provider is in the various plans' networks, and whether your medications are covered by those plans," Diehl says.

She also recommends that those signing up through exchanges get help from designated, government-funded enrollment navigators or assisters located in most cities and many rural areas. You can locate one nearby through healthcare.gov by going to " Find Local Help."

Crunch Dollars and Cents Upfront

Take into account plan deductibles -- including out-of-network versus in-network for preferred provider organization, or PPO, plans -- and out-of-pocket limits, says Nicholas Moriello, a health insurance broker and president of Health Insurance Associates in Newark, Delaware.

Then go a step further in your cost assessment. Plans commonly use a tiered coverage system, in which drugs -- including some for mental and behavioral health -- falling into higher tiers receive less-robust coverage, resulting in higher out-of-pocket costs for consumers, says Moriello, who is also a member of the national legislative council for the National Association of Health Underwriters, an industry trade group. Check to see not only whether your medications are covered, but to what degree.

He suggests looking for a plan that covers a larger network of providers, like a PPO, and that also offers out-of-network benefits. This would enable patients to see an out-of-network provider and not be "totally without coverage," he says. "One area of specialty [where] that tends to come up more frequently than others is in rehab, [including] addiction treatment."

To further evaluate what you may pay, go over any anticipated mental health care needs with the navigator or health insurance broker who might be helping you find a plan. This would include detailing things like: "'I want to see a therapist once every three months; I'm going to see my psychiatrist once every six months; these are the medications I take,'" Diehl says. "Get down to that sort of level of detail so they can actually do a dollars-and-cents analysis for you."

Mind the Coverage Gaps

Some mental health services are simply unlikely to be covered. Seeing a credentialed therapist who isn't a psychiatrist or psychologist? "Oftentimes that counselor visit is not going to be covered, regardless of the plan," Moriello says. The Affordable Care Act expanded what plans are required to cover, but counselor services aren't on the list of essential health benefits, he says.

Similarly, psychiatrists frequently don't accept any insurance, with many saying reimbursement rates lag those for other physicians. Plans that offer out-of-network coverage may be able to defray at least some of the cost of seeing mental health providers who don't accept insurance or are outside an established network.

Angela Kimball, associate director of policy at NAMI, says another potential strategy to access mental health services involves contacting primary care providers in your plan's network. "Ask in advance whether any of them operate under a medical home model and have behavioral health consultants or behavioral health experts on staff and provide team-based care," she says. "Because if you do that, then significant portions of your mental health care may be covered under your physical health care benefit, in the context of primary care."

The patient-centered medical-home concept is supported by the Affordable Care Act, and is seen by many experts as a more holistic approach to treatment. "But not every primary care setting provides a team-based approach or has mental health professionals on staff doing team-based care," Kimball says.

Where options for mental health care are limited, such as in rural areas, Diehl suggests checking to see if your plan covers telehealth, or telemental health. "Many commercial plans cover telemental health ... You can get therapy from your home or you can go to a satellite office and see a specialist over a secure Internet connection," she says.

Moriello adds that many insurance companies will offer assistance to patients with certain conditions, ranging from bipolar disorders to addictions, whereby a professional, like a nurse employed by the insurer, will advise on how to get the most from insurance benefits to cover care. He says such advocates aren't actuaries or out to interfere with needed care to cut insurance company costs, and adds that patients are always encouraged to follow up with their providers to make any care decisions.

Bedrock advice for saving money on general health care can also yield mental health savings, Moriello and NAMI reps say. This includes contributing to pretax dollar health savings and flexible spending accounts; shopping for lower drug prices and talking with providers about whether a generic medication is appropriate (sometimes a seemingly minor medication switch could have a significant negative effect on mental health, experts say, so check first before making a change); and engaging in self-care, ranging from eating well and exercising to not putting off doctors' visits.

Appeal, Appeal, Appeal Claim Denials

A report released earlier this year by NAMI criticizing a lack of "true parity" between mental health coverage and medical coverage found, among other issues, a higher rate of denial for insurance claims related to mental health services, as compared with other medical claims. The finding is based on a survey of about 2,750 people that was completed last year. "Anecdotally, for a long time we've known that mental health services seem to get denied by health plans at a higher rate than general medical primary care services or many kinds of medical specialty services," Diehl says.

But Clare Krusing, a spokeswoman for the industry group America's Health Insurance Plans, says plans have long supported the Mental Health Parity and Addiction Equity Act of 2008, a federal law enacted to prevent plans from imposing less favorable limits on mental health and substance abuse disorder benefits, as compared with medical and surgical benefits.

"Health plans have a unique understanding of the serious challenges patients and their families face when it comes to managing behavioral health conditions," Krusing says. "They work in close coordination with providers, specialists and families to develop care plans that address the individual needs and circumstances of each patient and bring to bear all available treatment models and levels of care. The goal is to ensure patients have access to the right care, at the right time and in the right setting."

She adds that there is a great deal of transparency surrounding how plans implement coverage decisions. "These clinical guidelines are developed in close coordination with medical societies, and health plans make those coverage decisions available to patients and providers as well," Krusing says. She adds that if patients or providers do have questions about care, "health plans work to provide the information they need to ensure patients are getting access to the right type of care."

But critics say frequent insurance denials make difficult situations worse for patients. However, patients may have the last word on many claim denials, whether for medical or mental health services, since data from the U.S. Government Accountability Office shows that 39 to 59 percent of health insurance claim denials are eventually overturned.

"'No' doesn't always mean 'no,'" Kimball says. "Don't accept a 'no' until you hear it three times." Start by appealing a claim denial internally with your insurance plan, and appeal a second time if the first appeal is denied. She notes that the Affordable Care Act provides the opportunity for an independent external review on a third appeal.

"I think that's important for consumers to know because it's sometimes very perfunctory that health plans will just say no on principal," Kimball argues. She adds that it's important for those seeking mental health services to battle that. "Mental health parity is the law, and when your claim has been denied and you think it's unjust ... you have the right to go to your state's insurance commissioner, you have the right tell your story [and] to contact people to get help."

Michael Schroeder is a health editor at U.S. News. You can follow him on Twitter or email him at mschroeder@usnews.com.