Accessing Insurance for Mental Health Services Katie Hornberger, Director, Office of Clients’ Rights Advocacy Disability Rights California

Today We Are Covering Insurance Coverage for Mental Health Services How to Request a Service Denials of Service Intersection of Regional Center and Insurance

Types of Insurance Private Insurance Self Funded Plans HMOs, PPOs, etc Self Funded Plans Public Insurance Medi-Cal Medi-Care

Who Governs Insurance Companies All health plans that provide hospital, medical or surgical treatment and that are under the jurisdiction of the Department of Managed Health Care (DMHC) or the Department of Insurance (CDI) are covered except: Self-funded plans that may be administered by a health plan. Medi-Cal.* Federal government employee plans (i.e., TriCare). Out-of-state plans depending on the state.

Requesting Services The service is requested from a qualified provider. From the time of funding request by a provider, the health plan has five days to determine if funding will be provided or to request additional information needed to make a decision. Once a decision to fund has been made, an appointment must be offered that is within 10 business days for a non-physician mental health worker or 15 business days for Occupational therapist (OT), Speech Therapist (ST), or psychiatrist.

Appeals and Complaints Internal plan grievances must be resolved within 30 days. DMHC and CDI handle complaints if the health plan states the reason for denial is the lack of coverage for a benefit. If the reason for denial is lack of medical necessity, an independent medical review can be requested from CDI or DMHC which will be resolved in 30 days. For urgent needs that threaten health, all of the processes can be expedited.

Medi-Cal Managed Care Grievance IMR Hearing

Medical Necessity In accordance with the generally accepted standards of medical practice; Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and Not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.

Network adequacy Ability of a health plan to provide enrollees with timely access to a sufficient number of in- network providers, including primary care and specialty physicians, as well as other health care services included in the benefit contract.

Coordination of Services Regional Center Local Educational Agency Dual Coverage Gap Coverage Copays/Deductibles

Resources Tips for Working with Your Insurance: Keep Asking, (Politely!) at http://www.disabilityrightsca.org/pubs/CM4001.pdf Ensure Your Health Insurance Provides Equal Coverage for Mental Health Benefits at http://www.disabilityrightsca.org/pubs/CM3201.pdf Mental Health Parity under California and Federal Laws at http://www.disabilityrightsca.org/pubs/CM2401.pdf Timely Access to Medical Care at http://www.disabilityrightsca.org/pubs/555601.pdf Extra Services for Children and Youth Under The Medi-Cal EPSDT Program at http://www.disabilityrightsca.org/pubs/552601.pdf Payment by the Regional Center for Insurance Copays, Coinsurance, and Deductibles at http://www.disabilityrightsca.org//pubs/F10201.pdf

Appeal Resources Private Insurance Appeals Including Independent Medical Review (IMR) for Health Plans under the Authority of the California Department of Managed Health Care (DMHC) or Department of Insurance (DI) at http://www.disabilityrightsca.org//pubs/F07201.pdf Medi-Cal Managed Care: An Independent Medical Review (IMR) Can Change a Plan’s No to Yes at http://www.disabilityrightsca.org/pubs/553401.pdf The California Mental Health Parity Act Toolkit at http://www.disabilityrightsca.org/pubs/CM5401.pdf