“What If My Insurer…?” – Cover My Mental Health

"What if…?

Common Insurer Obstacles – What If…

… my insurance is through Medicaid

Coverage for mental health care under Medicaid can be challenging, just like with private insurance. With Medicaid, there may be additional issues specific to the features and limitations of someone’s specific state Medicaid program, federal Medicaid rules, and the individual insurance plan.

This Quick Guide identifies how the resources of Cover My Mental Health may be helpful. It also shares additional sources of support specific to Medicaid.

DOWNLOAD the Quick Guide for Medicaid

… my insurance is through Medi-Cal (California’s Medicaid)

Coverage for mental health care under Medi-Cal can be challenging, just like with private insurance. With Medi-Cal, there may be additional issues specific to the features and limitations of specific Medi-Cal rules and the individual insurance plan.

This Quick Guide identifies how the resources of Cover My Mental Health may be helpful. It also shares additional sources of support specific to Medi-Cal.

DOWNLOAD the Quick Guide for Medi-Cal

… my insurer says they will cover different care than my clinician suggests?

With insurer feedback such as the above, check out Denied: not medically necessary.
Different level of care pushback may look like these:

Fewer appointments are approved than the provider has determined is appropriate
Only out-patient care is covered, when the provider has determined that intensive out-patient or partial hospitalization is appropriate.
At higher levels of care (for example, in-patient), an insurer determines that enough progress has been made, so a lower level of care is now appropriate; the provider does not agree.
At higher levels of care (for example, in-patient), an insurer determines that not enough progress has been made, so that care is no longer covered; the provider does not agree.
Intensive out-patient care is not covered, but out-patient care is covered

… my insurer says the recommended care is not covered by the policy?

Maybe.

Best to have a complete copy of your insurance policy. See Action Plan “Request a complete copy of your insurance policy”

Ask a customer service rep exactly where in the insurance policy they see an exclusion or reason to say the care is not covered.

See Action Plan for “Tips when talking with insurance company customer service reps”

Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.

Guidance for filing a formal insurer complaint

… I can not get a clear answer from my insurer?

This may be quite frustrating… whether they are unclear about your care or a claim or a denial.

It may be helpful to have a complete copy of your insurance policy. See Action Plan “Request a complete copy of your insurance policy”

Ask a customer service rep exactly where in the insurance policy they see an exclusion or reason to say the care is not covered.

See Action Plan for “Tips when talking with insurance company customer service reps”

Still not clear? Consider asking for help from your employer or filing a formal insurer complaint.

Guidance for filing a formal insurer complaint

… I have some other obstacle with my insurer?

We welcome inquiries about other insurance obstacles at contact@covermymentalhealth.com.

Please do not share urgent requests, though we will endeavor to respond on a timely basis. Please do not share personal health information in your email; see our Privacy Policy.

Cover My Mental Health does not provide medical or legal advice.

Inquiries about other insurance obstacles may help us to expand and improve the resources provided on this site. Thanks.

More Challenging Scenarios – What If…

… I’m having issues with approval to enter or stay in residential care?

Insurance barriers to residential care may include:

a network directory without a suitably competent program,
denials of care as “not medically necessary,”
required reduction in level-of-care contrary to clinician’s determination, or
opaque processes.

Download the Quick Guide for Residential Care resources

A clinician’s documentation of the appropriate care may prove helpful when facing challenges accessing a suitable program, including a competent clinical team (that is, documenting what expertise is required), overcoming denials for “not medically necessary,” and insurer requirement to reduce level-of-care. As a treatment plans proceeds, follow-on medical necessity letters may help.

Medical necessity letters – how this resource supports your access to care
Medical necessity letter template (provided by a clinician on patient request) [download]

A common obstacle to residential care is the lack of an in-network program available in a timely manner, nearby, and with the required specific clinical competency. Here are resources toward overcoming this obstacle:

…my teen’s psychiatrist is recommending specialized care and my insurer says we should use a lower level of care they offer in-network?

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).

… our daughter is progressing in residential treatment and our insurer just said they will cover only three more days of care?

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.

For this obstacle, the insurer’s guidance for your daughter’s level of care differs from the clinical assessment at your daughter’s treatment center.

It may be helpful to think of this as a denial for “not medically necessary” since the insurer is apparently denying the clinical decision of the residential treatment center.

The downloadable medical necessity letter template may be useful to document the clinical assessment by your daughter’s psychiatrist (or by the most senior clinician at her residential treatment center).

The letter might reference the short timeline your insurer is mandating for a change in level of care. For example, include an assessment of the potential danger and the risk to her care and recovery of leaving the residential program.

A template transmittal letter is also available to download. That transmittal can be used to share the clinician’s letter with your insurer.

Lastly, suggestions for what to say to an insurer customer service rep are provided on the website (see medical necessity denials).

Our resources

"What if…?

Common Insurer Obstacles – What If…

More Challenging Scenarios – What If…