“What if…" and FAQs
What if…
While we cannot offer specific medical or legal advice, here is how the resources of Cover My Mental Health might be helpful. Please consider seeking medical and/or legal advice as appropriate.
This situation combines two insurer obstacles for which we provide actionable resources:
- “Denied: not medically necessary” – the psychiatrist’s assessment of the appropriate care is not accepted by the insurer.
For this obstacle, the downloadable medical necessity letter template can document the psychiatrist’s determination of the required care. The template includes instructions to guide the psychiatrist’s preparation of the letter, including referring to the insurer’s denial that is considered inappropriate.
- “No in-network provider” – for the recommended care, the next-step required clinician/provider (e.g., intensive outpatient, partial hospitalization, residential) is apparently not available in the insurer’s network.
For this obstacle, using the downloadable worksheet can document that the insurer’s suggested clinicians have been reviewed (including by the psychiatrist) and are not appropriate to the go-forward treatment plan.
These two downloadable resources can be shared with your insurer to request their coverage of the required care as required by the insurance policy.
Suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials or no in-network provider).
FAQs
Experts point to many explanations for this, including:
- Stigma,
- Historical exclusion of coverage, and
- Higher subjectivity in diagnosis and treatment compared with medical/surgical conditions
…to name a few reasons
Despite these explanations, there is growing recognition that mental health is simply another part of health… and that access to care can and must be improved.
In some cases, that is true.
Still, many individuals and families encounter significant obstacles to care including finding suitable providers or facilities with availability and getting services covered by health insurance.
Three emerging developments have significant potential to improve insurance access:
- New state and federal regulations requiring insurance companies to cover mental health care;
- Reductions in stigma; and
- Growing consumer expectations of coverage
Your use of the resources provided here can make a difference for you and for others.
Send your question to [email protected] and we’ll try to respond… and perhaps include your question in this FAQ resource.
