Understanding Insurance for Mental Health

Affordable health care, including mental health care, should be available to everyone. Unfortunately, understanding insurance is no easy task and navigating through state-funded insurance can be even trickier. We have put together a short guide to try to make the process easier.

How does insurance pay?

Insurance companies set up contracts with providers that lay out the fees that will be charged to patients and what the insurance companies will pay for these services. When a provider is “in-network,” it means that they have this contract set up with the insurance company. Some insurance plans will only pay for services with in-network providers and some plans will also pay out-of-network providers. When services are rendered, the provider typically knows your estimated co-pay based on the contract, and a claim is submitted to the insurance company. The insurance company reviews the claim and issues the agreed upon payment. Unfortunately, claims may be denied by the insurance company, resulting in a higher patient payment. These decisions can be appealed by the provider and typically require an explanation of the medical necessity of the services.

Mental Health Coverage

Since 2014, most insurance plans are required to cover mental health services and all state Medicaid plans have some type of mental health coverage, including CHIP (Children’s Health Insurance Plan). This coverage extends to therapy, substance use disorder treatment, social work services, and medications. The best way to find out what services your plan covers is to look up the enrollment materials for your plan. As part of the Affordable Care Act, insurance companies are required to provide an easy-to-understand breakdown of coverage in these enrollment materials and online. You can also check with your insurance company and they can connect you to in-network providers in your area.

Medicaid Eligibility

Medicaid is a specific coverage plan under the bigger umbrella of medical assistance programs to help those who cannot or are struggling to afford insurance and healthcare. To qualify for Medicaid in Pennsylvania, you must be: a PA resident, a U.S. national, citizen, permanent resident, or a non-citizen who is legally living in the country; uninsured or under-insured, in a financial situation that would be characterized as low income. You must also be either pregnant, be responsible for a child 17 years of age or younger, or have a disability or a family member in your household with a disability. To find out more about if you meet these requirements and apply for coverage, visit https://www.benefits.gov/benefit/1148.

Therapy Without Insurance

Mental health services without insurance coverage can be costly, sometimes up to $100 per hour or more. However, there are options for low-cost therapy. Finding an office with a sliding-scale, meaning cost varies based on the client’s ability to afford the treatment, is a great place to start and you should check with your provider to see if that is an option or if they have any other payment options. There are also several federally-funded mental health treatment centers in the area. Feel free to check out http://findahealthcenter.hrsa.gov/ to find the center closest to you.

To find about more about insurance resources for mental health services, visit https://www.mentalhealth.gov/get-help/health-insurance

Another great resource for free mental health information is https://www.samhsa.gov/ or you can check out https://www.nami.org/home to find out even more.

What have been your biggest struggles in navigating and understanding insurance? Is there anything you would like to know more about? Have you delayed looking for therapy for your child because of the issues you’ve heard about or encountered for mental health services?

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