Mental Health & Autism Health Project Families Seeking Mental Health Residential and Other Related Treatments

Final regulations published by the Federal Mental Health Parity & Addictions Equity Act explicitly state that residential treatment is a covered benefit. These regulations became active on July 1, 2014 and after, as plans renewed. These regulations impact nearly all health plans, except for grandfathered plans and a small number of ERISA exempt government plans.

MHAIP has had success in obtaining insurance coverage for medically necessary residential, partial hospital programs, and intensive outpatient treatments for adolescents and young adults with mental health conditions. The new regulations have changed the landscape for residential treatment coverage. When medically necessary, it should be covered for most health plans.

I AM CONSIDERING RESIDENTIAL TREATMENT

If you are considering admitting your child or young adult to a Residential Treatment Center, and would like to receive coverage, follow the steps below to maximize your chances of obtaining insurance reimbursement. You may also contact us to assist you in the process as we have successfully recovered up to $100,000 for individual families.

  • • Document the behaviors that warrant admission, and obtain documentation of these behaviors from licensed professionals, school personnel, and medical doctors. Behaviors include uncontrolled risk taking that creates an immediate risk to self or others; rapid decrease in level of functioning in several areas of life (school, family, interpersonal), to the degree that the individual is unable to care for him or herself, and/or likelihood that individual will not improve in their current environment.
  • • Children typically should receive some level of "out-patient" care, such as weekly psychologist visits, in order to justify the need for more intensive treatments, although if there is a significant precipitating event, or if the child repeatedly refused to go to therapy, we have been able to bypass this. This type of requirement, known as “fail-first,” is thought to be a violation of the Federal Mental Health Parity Act and can be challenged with insurance carriers.
  • • Prior to admission, contact your health plan for a list of "in-network" residential treatment centers. If none of them are appropriate for your child, make a written request for approval to a specific out-of-network facility prior to admission and document why and how this facility can accommodate your child's unique, medical needs in a way that the in-network facilities cannot.
  • • Be sure that the residential treatment center is licensed as residential. Inform the management of the RTC that you will be seeking insurance reimbursement, and have them contact your insurance company at the start to obtain pre-authorization. They should obtain a tracking number, verifying the call. If the services are approved, they should request a written authorization confirming admission approval. The RTC will need to comply with the standards of the state they are located in, not the state that you are from.
  • • If the request is denied, the insurance company is legally required to inform you of this in writing. Like with other denials, how you frame your appeal will depend upon the reasons for denial. If they tell you that an RTC is not a covered benefit, this can be successfully disputed given the new regulations of the Federal Mental Health Parity Act.
  • • You can cite the Federal Mental Health Parity Act, the ten essential benefits of the Affordable Care Act and Harlick v. Blue Shield of California, filed August 26, 2011: “Harlick and her doctors ultimately determined that none of the in-network facilities suggested by Blue Shield could provide effective treatment, so she registered at Castlewood Treatment Center, a residential treatment facility in Missouri that specializes in eating disorders."

OUTDOOR BEHAVIORAL THERAPY (AKA “WILDERNESS THERAPY”)

We have successfully helped many families obtain coverage for Outdoor Behavior Therapies. We’ve done this both by calling in and obtaining pre and ongoing authorizations, as well as by sending in all claims and medical records after the fact. Many plans will dispute Wilderness therapy and say that it is harmful, experimental or unproven. But we have taken the time to educate regulators, attorneys, and others in the field and share the wealth of evidence based literature amassed on the subject. We have won many appeals in multiple states. We believe that the intent of the federal mental health parity act is to support a broad spectrum of medically necessary, evidence based mental health treatments. In states that require separate licenses for residential (indoor) and Wilderness (outdoor) programs, requirements are nearly identical. We believe that excluding a treatment because most of it takes place in an outdoor setting is a type of non-quantitative treatment limitation which is a violation of federal MH parity. Like behavioral health treatment for autism 5-10 years ago, the research for this treatment demonstrates that it is an effective therapy for many mental health conditions.

AETNA's FAQ on the Federal Mental Health Parity Act (If you have Aetna, either self-insured or fully funded, and they are denying residential treatment benefits, show them their own document.

Services That We Offer

  • MHAIP is here to help. We file appeals and grievances on behalf of individuals seeking mental health treatments on a sliding scale fee. We handle regulatory intervention and external reviews with state regulators.
  • If your facility does not work with insurance, with their permission, we will draw up and submit claims and medical records, conduct pre and ongoing authorizations,as well as train your facility on how to work with insurance.
  • We have amassed a national team of attorneys that we hand cases off to if we are denied. Many will work on a contingency basis.

Aditional Resources

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