By Cecily Ruttenberg, Mental Health & Autism Insurance Project 

Families that have a loved one who is struggling with mental health issues or autism spectrum disorder are now in a better position than ever to seek intensive treatment for their adolescent or young adult. Final regulations under the Federal Mental Health Parity Act—in effect as of January 1, 2015 for nearly all health plans—state unequivocally that residential treatment (RTC), partial hospitalization (PHP), and intensive outpatient (IOP) must be covered by health plans when medically necessary in parity with medical conditions. This includes self-insured ERISA plans, Affordable Care Act plans, and state-regulated plans.

Independent educational consultants (IECs) play an important role in helping their clients obtain health insurance coverage. IECs can take the following specific steps to help their clients:

Look first at the in-network RTCs. When choosing a program, IECs have typically looked for the best program without considering health insurance. Times have changed. Your client will have the greatest chance of monetary coverage if you choose an in-network facility. Ask your client to request a list of in-network treatment programs from their insurer and at least look it over to see if one of them might be a good fit.

Consider out-of-network treatment programs that work with insurance. Choosing an out-of-network treatment program is not necessarily a bad choice, because a family’s plan may cover anywhere from 50% to 90% of the cost. Treatment programs vary wildly, however, on how they help families work with insurance. Choose a treatment program that provides preauthorization; ongoing utilization review; and billing for the entire cost of treatment, not just individual sessions. Make it a point to find out if the program you are recommending offers those very specific services.

Wilderness programs. Some wilderness programs do work with insurance companies by doing preauthorizations, utilization reviews, and billing. Most of them will provide a breakout bill for individual, group, and family therapy sessions, but far fewer support families in billing for the entirety of treatment. Be sure to ask.

Licensing matters. When choosing a treatment program for your client, favor those that are licensed for the step-down levels of care: PHP and IOP. For example, if your client goes to an RTC that is also licensed for PHP and IOP, the client will likely get funded for a much longer stay than if they attend a program that is only licensed for RTC. That is because insurance companies rarely will fund longer than one to two months of residential treatment, but they will follow those months funding PHP and IOP, which would allow your client to stay in the program and continue collecting insurance dollars for up to six months or more.

HMO insurance. If your client has HMO insurance and there are no appropriate treatment programs in-network, all hope is not lost. Your client can argue that their insurance has an inadequate network (which is illegal) because they have no clinically appropriate program for a given patient, and therefore they must fund the program you choose.

School District Funding

Insurance companies are designed to deal with acute mental health crises and are likely to fund the first several months of treatment if the proper protocol is followed. For longer term RTC or therapeutic boarding school costs, parents should look to their school district. The school district is the best source of long-term funding for kids with ongoing, serious mental health needs. When approaching the school district, it is best to retain a local special education attorney who is experienced working with the local school district. Families can reach out to their local NAMI or special needs community for an attorney recommendation.

Occasionally, families recover funds from both the school district and health insurance for the same time period. Should that happen, families must return one or the other funding sources as it is illegal to double dip. There is no reason, however, not to seek both from the beginning because you never know what will come through.

What Families Should Do

1. Obtain a letter from the teen’s therapist stating that outpatient therapy was attempted but a higher level of care and structure, as is found in an RTC, is clearly needed. In most cases, teens should be receiving outpatient treatment before going to RTC. Insurance companies will want proof that less-intensive treatment was attempted—and was ineffective—before they agree that RTC is medically necessary.

2. Call the insurer, tell them that their child needs RTC, and request a list of the in-network facilities. Write down the date of the call, name of the person helping you, and obtain a tracking number. Do this with all your future communication with your insurance company.

3. Research the in-network RTCs to determine whether they are an appropriate fit or ask your IEC to do it for you. Write down the reasons why programs are not clinically appropriate for your child. That may help you get costs covered at the in-network rate.

4. When your child does go to treatment, be sure the treatment program calls and requests preauthorizations. That is a critical step.

Obtaining insurance coverage for residential treatment is not an easy process, but the law requires coverage of mental health treatments in parity with medical treatments. Insurance is a service you pay for, and as such, you and your family are entitled to those benefits.

Cecily Ruttenberg can be reached at [email protected] The Mental Health and Autism Insurance Project (www.mhautism.org) is a nonprofit organization that helps families and providers secure insurance coverage for interventions related to autism and mental health disorders.