CT develops guide for getting insurers to pay for mental health, substance abuse care
State insurance officials have released a “toolkit” they hope will make it easier for Connecticut residents to get coverage for mental health and substance abuse treatment.
The nine-page document provides guidance on what questions to ask health care providers and insurers to help ensure that care will be covered, and it includes a checklist of information to gather for those who want to appeal denied claims. Officials developed the guide with experts from the UConn Health Center and insurance companies.
It grew out of the perception among insurance officials that many of the problems people face getting services covered were the result of issues in the claims process — such as incomplete information or documentation problems — rather than insurers’ skirting coverage rules.
Too often, families get a child situated in a treatment facility or with a behavioral health service without anyone contacting their insurance company, said Anne Melissa Dowling, the state’s deputy insurance commissioner.
“It’s just been heartbreaking, what we hear,” said Dowling, who oversees the department’s health insurance initiatives.
Insurance companies have faced significant criticism for their handling of mental health and substance abuse services in the past year. During a public hearing last fall, parents and psychiatrists spoke of insurers denying coverage for needed residential treatment or stopping paying for inpatient care well before teens with psychiatric disorders were ready to be discharged.
The issue got more attention in the wake of the massacre at Newtown’s Sandy Hook Elementary School last December. Many people voiced frustration about their insurance coverage, describing it as a barrier to getting their children help.
The insurance department has also faced criticism for not doing enough to enforce laws that require insurers to treat mental and physical health care equally. The department has said that ambiguities in the existing regulation make it difficult to do more.
But department officials determined that they could help people avoid pitfalls that frequently lead to claims being denied.
While medical providers typically participate in insurance company networks and handle billing themselves, mental health providers often aren’t in insurer networks, and patients are left to pay the providers and seek reimbursement from their insurance company.
Dowling said families seeking mental health or substance abuse services should first find out what their plans cover. Often, insurance companies require that services be deemed “medically necessary” to be covered, and Dowling said it’s important for the health care provider to be involved in getting the right information to the insurance company. If the provider won’t get involved, she added, the insurance department’s consumer affairs unit (860-297-3900) can help.
The tool kit urges people to consider using providers that are part of their insurance carrier’s network, and notes that it can be more challenging to get paid back for care provided by out-of-network clinicians or facilities. It also offers guidance on what people should do if they need to use a provider or facility that isn’t in their insurance company’s network.
Those working on the tool kit were mindful that people using it will likely be going through difficult times, and so they aimed to make the language as accessible as possible, Dowling said.
“We need this to be comprehensible in a moment of stress,” she said.
Advocates for mental health and substance abuse treatment services have said making the process easier for people to understand is a good step, but that there are still problems with insurance coverage that go beyond how claims are filed.
Dowling said the department’s next step will be to focus on compliance with mental health parity laws.
The toolkit is available by clicking here.
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