You might not always be able to spot the symptoms of a brain illness, but it’s more common than you’d guess. In any given year, one in five American adults struggles with conditions like depression, anxiety, and substance abuse. All those behavioral health conditions are considered brain illnesses.
But fewer than half of these affected Americans will receive treatment that can make them better—or even save their lives. One big reason: out-of-pocket costs. Federal law requires insurance companies to cover mental health conditions in the same way as medical care for, say, arthritis, cancer, and diabetes. Unfortunately, this isn’t always the case.
This isn’t a new issue. Behavioral health conditions weren’t adequately covered in many traditional health insurance plans, until the Mental Health Parity and Addiction Equity Act (MHPAEA)—otherwise known as the Federal Parity Law—was signed in 2008. It was subsequently strengthened as part of the Affordable Care Act. The law requires most insurance plans pay for mental health, eating disorders, and addiction care, the same way they cover physical health problems.
This means if you have a $10 copay to see your doctor for the flu, you should have a $10 copay to see your doctor for depression, anxiety, or addiction. Sounds good—in theory. But in practice? Not so much.
According to a 2017 report commissioned by the Mental Health Treatment and Research Institute, behavioral health providers, such as psychiatrists and psychologists, were paid 21% less than doctors who treat physical health, like family or internal medicine doctors.
This pay disparity means fewer behavioral health providers participate in insurance networks—and that means patients often must go to out-of-network doctors for behavioral health care.
This means, says Dr. Rupali Chadha, MD, a psychiatrist in Norwalk, California, “if your medical coverage isn’t great, your mental health coverage isn’t great either.”
The result: higher copayments—and higher costs—for those coping with mental health issues. Forced out of their network, patients must pay their doctors in cash, at rates that start at about $100 a visit.
And that’s not the only problem people face when they’re seeking mental health care.
“Insurance companies can put up lots of obstacles,” says Roland Lamy, executive director of the New Hampshire Behavioral Health Association. “They use the traditional insurance tactics, like restricting networks, rejecting authorization requests, limiting services that are covered, and denying claims. It’s death by a thousand papercuts.”
Some people just don’t have the money to pay out of pocket, so they skip treatment altogether, which often has tragic results: those who don’t get the care they need often die of overdose or suicide. That makes parity a matter of life and death.
Here’s a guide to the Parity Act—and tips to help you navigate the system—so you can get the care that the law entitles you to.
4 Things You Should Know About the Parity Act
Knowledge is power, so learn everything you can about parity for behavioral health conditions. Start with these four facts.
- If your health insurance plan covers both medical and mental health benefits, your deductibles and copayments—and treatment limitations—must be the same for both. That means that if you have a $10 copay for your asthma medicine, you should also have a $10 copay for your anti-depressant. And if you’re allowed 10 visits with your doctor to get your diabetes under control, you should also be allowed 10 visits with your therapist to treat your anxiety.
- Your plan must offer the same out-of-network provisions for mental health and substance use conditions as it does for physical health conditions.
- Do you have to meet a deductible amount—say $500—before your insurance starts paying for your health care? Then your behavioral health and physical health must be part of that same $500 deductible. Separate deductibles for medical and behavioral health are against the law.
- If your insurance company turns down your claim for behavioral health or substance use care, it must provide a reason for the denial if you ask for it.
How Mental Health Is Covered
Despite the law, there are several situations in which insurance companies may make it difficult to have your behavioral health regimen covered. Here are some ways that health plans affect the cost of your treatment:
- They force you to meet separate deductibles for behavioral health services and other health services.
- They charge you a higher copayment for behavioral health care.
- They limit the number of days of inpatient care for behavioral health.
- They allow fewer office visits for behavioral health care.
- They charge more for behavioral health prescriptions.
- They require special authorization before you can start—or continue—behavioral health treatments.
- They insist that you try one treatment, even though your doctor says you need a different one. This is known as the “fail-first” strategy—you waste time on a less expensive treatment that your doctors know probably won’t work, before you can begin the treatment that they know probably will work.
- They won’t pay for behavioral health care outside your state or region, which could put you at risk when you travel.
When it comes to behavioral health, many insurance companies and BHOs tend to turn you down.
“Become educated,” advises Carneal. “Get familiar with your insurance policy and all the related plan documents to understand what’s covered and what’s not. And learn the process for filing an appeal. There are lots of moving parts.”
What to Do if Your Insurance Denies Your Mental Health Claim
Golden rule: Don’t take no for an answer. “It’s very difficult for patients and their families—and their providers—to track why a recommended treatment isn’t being covered,” says Carneal. Parity law could be on your side.
The appeals process can be daunting—and time-consuming. “Behavioral illness isn’t like other illnesses,” says Dr. Chadha. “With cancer, you may be weak but you can still make a phone call. But when you have a behavioral illness, you’re not only physically exhausted, [but] you’ve got a cloud of hopelessness over you.”
Here are some helpful tips to open up the conversation with your health plan:
- Find a helper. Ask a family member, a trusted friend, or even a professional advocate to speak up for you. “Establish a community of contacts,” says Corneal, “including consumer advocates and others to help you when issues pop up.” Connecting with a regulator who knows the ropes can also be helpful, he adds.
- Make sure your doctor is in the loop. Let your primary care provider know what’s going on. “We’re happy to help,” says Dr. Chadha. “We don’t do this for the big bucks—we do it because we care. We can write a letter or call your insurance company to tell them that you need a specific treatment. We can use the big scary words that often get results!”
- Keep careful records. Make copies of all your claims and all correspondence with your insurance company, as well as copies of all your bills for behavioral health care. Have a notebook to jot down the main points of all your phone conversations about your claim—be sure to include names, titles, and dates.
- Know your resources. Your best bet: check out one of The Kennedy Forum’s websites, which are dedicated to helping people receive the behavioral health benefits they’re entitled to. You’ll find all the information you need to get started—from guidance on how to write an appeal letter, to the names and addresses of insurance commissioners and legislators in your state.
- Be prepared. Getting ready to call a random bureaucrat at the insurance company? Don’t freak out. “A call like that can be really anxiety-provoking,” says Dr. Chadha. “So write out a little script beforehand of everything you want to say. Tell the insurance representative that you don’t want to get sicker, so you need to receive the care your doctor recommends. Let them know that the earlier you get the care you need, the less expensive it will be. Don’t give up—every single person is valuable and lovable and deserves good care.”
- Ask about Genomind Professional PGx Express. It’s a genetic test that can help your doctor make a more informed treatment decision. The results can help your providers determine an effective and well-tolerated course of treatment. Talk with your doctor and insurance representative about it.