THE BLOG

How Can I Get My Health Insurance to Pay for Mental Health Treatment?

02/09/2015 12:50 pm ET | Updated Apr 11, 2015
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This weekly Q&A addresses questions from real patients about health care costs. Have a question you'd like to see answered? Submit it to AskChristina@nerdwallet.com.

Question:

My 15-year-old son struggles with depression. Our health insurance company refuses to cover his inpatient mental health treatment, despite multiple doctors saying it's necessary. We simply can't afford to pay out-of-pocket for inpatient psychiatric care. Where do I go from here?

Answer:

Your son is one of millions of Americans who deal with depression every year, and though changes in recent years have made it easier than ever to get mental health treatment, coverage for long-term inpatient care remains a notoriously difficult problem.

The first thing to remember is you're not alone. A recent segment on 60 Minutes profiled several families who struggle with this same situation. Navigating health insurance coverage when your child is suffering is no easy feat, particularly when you are concerned about his or her safety.

Your rights under recently changed regulations

The Affordable Care Act requires all compliant plans to cover mental health treatment in the 10 essential benefits that must be on all health insurance policies. But that isn't the only change to mental health coverage in recent years.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, known as the mental health parity law, requires mental health coverage to be comparable to other medical coverage under your plan. In other words, the law mandates insurers cover mental health in a similar manner to physical health coverage. While this did away with many previous obstacles consumers faced when seeking mental health treatment, it didn't solve all coverage problems.

Review your denial.

When a claim is denied, the insurance company mails out an explanation of benefits (EOB). The EOB will look similar to a bill and will likely include codes providing clues to how the company arrived at its decision. You should look here first for the insurer's justification for denial. If you're still unclear on why it was denied, call them. You have a right to know why the claim wasn't paid, and understanding their justification will help you map out an appeals plan.

Sometimes denials are based on simple mistakes in billing, misspelled names or the wrong policy number being entered. These are relatively simple to resolve, but it sounds like your denial may be more complicated.

Starting now, if you haven't already, make it a practice to write down every conversation you have with the insurance company. Include the date, time, whom you spoke with and what was discussed--and make sure to ask the agent you speak with for a call reference number so you can refer back to it during future conversations with your health insurance company if necessary.

Consider working with a medical billing advocate.

Medical billing advocates work with consumers in ensuring they get the care and coverage that's due to them. The appeals process can be overwhelming. These professionals can assist you in navigating all of the paperwork, deadlines and phone calls. But you don't have to enlist an advocate. If you'd rather go it alone, it's well within your rights to appeal a health insurance denial.

Start the appeals process.

The appeals process varies among insurance companies, but you have a right to appeal their decision regardless of your carrier. Check its website and your EOB for details on how to begin the appeals process. If you have any questions on the specifics, call and ask. You don't want to waste precious time trying to decipher a complicated process if an answer is just a short phone call away.

Generally, you'll be required to submit a letter or standard appeals form. You'll need to do this within a set time frame--usually six months from the date of denial--so watch your calendar and make sure you get everything in on time.

The appeal is your chance to show the insurance company why your son's care should be covered. Properly filling out all the right forms before the deadline and including supporting evidence will increase your chances of winning the appeal.

Gather and submit your evidence.

Request copies of your son's medical records. There's a chance the insurance company was missing some of his doctor's recommendations or crucial pieces to his medical history.

Err on the side of giving them too much supporting information.

If your son's treatment providers believe inpatient care is necessary, ask for them to write a letter to that effect. Surely they've stated such in his records, but if the records weren't enough the first time around, they may not be substantial enough the second time either.

Anytime you send the insurance company paperwork--whether via email, fax or snail mail--be sure to include your policy and claim numbers. You want to give them as few opportunities as possible to misplace or not receive your communications.

Be prepared for a second denial.

There's a good chance the insurance company will deny your claim a second time. If this happens, the next step is an external appeal, where a third party will look at your claim and determine if coverage is warranted or if the denial was correct.

The external appeals process varies by state, with some states having adopted new Affordable Care Act guidelines that ultimately benefit you, the consumer. But even in states that have not adopted the new rules, you have a right to this third party review. For more information on where your state lies in this appeals process, visit this page from the Center for Consumer Information & Insurance Oversight.

If your son's situation is urgent, file both appeals.

If your son's life is in danger because of the denied claim, you may be able to expedite the appeals process by filing the internal and external appeals simultaneously.

According to rules under the ACA, the standard appeals process must "seriously jeopardize" your son's life or his ability to "regain maximum function" to qualify for the expedited appeal.

In this case, a final decision on your claim must come within 4 days of your request or as quickly as his medical condition demands it.

Stay hopeful, persistent and realistic.

Though mental health coverage laws have changed in recent years, health insurance companies can still deny claims, and your son's case is evidence that they do. It's true that the appeals process doesn't prove successful for everyone, but it's often your best chance of recourse when faced with a denied medical claim.