Insurance and Patient Financial Issues

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When it comes to our well-being, mental health is just as important as physical health. Unfortunately, insurers haven’t always seen it that way.  In the past, many health insurance companies provided better coverage for physical illness than they did for mental health disorders.

A law passed in 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (also known as the mental health parity law or federal parity law) requires coverage of services for mental health, behavioral health and substance-use disorders to be comparable to physical health coverage.

Did you know that parity laws require insurers to provide comparable coverage for mental health, substance use disorder, and physical health care so that people can get the treatment they need?

The U.S. Department of Health and Human Services has updated its mental health and substance use disorder parity website, which provides resources to help answer questions about protections under federal parity laws. The site is a guide for people who:

  • Have been denied coverage
  • Have reached a limit on their plan (such as copayments, deductibles, or yearly visits)
  • Have an overly large copay or deductible

Whether or not a plan is covered by federal parity law depends on the kind of health plan a person is enrolled in.  Health plans that must follow federal parity include:

  • Group health plans for employers with 51 or more employees.
  • Most group health plans for employers with 50 or fewer employees unless they have been “grandfathered,” which means it was created before the federal parity laws went into effect.
  • The Federal Employees Health Benefits Program.
  • Medicaid Managed Care Plans (MCOs).
  • State Children’s Health Insurance Programs (S-CHIP).
  • Some state and local government health plans.
  • Any health plans purchased through the Health Insurance Marketplaces.
  • Most individual and group health plans purchased outside the Health Insurance Marketplaces unless “grandfathered.”

Health plans that do not have to follow federal parity include:

  • Medicare (except for Medicare’s cost-sharing for outpatient mental health services do comply with parity).
  • Medicaid fee-for-service plans.
  • “Grandfathered” individual and group health plans that were created and purchased before March 23, 2010.
  • Plans who received an exemption based on increase of costs related to parity.

For comprehensive information on parity laws, please read this SAMHSA Document: Know Your Rights Rights: Parity for Mental Health and Substance Use Disorder


Check your description of plan benefits — it should include information on behavioral health services or coverage for mental health and substance-use disorders. Unlike some state parity laws, the federal parity law applies to all mental health and substance-use disorder diagnoses covered by a health plan. However, a health plan is allowed to specifically exclude certain diagnoses — whether those diagnoses are considered to be in the physical/medical realm or behavioral/mental health. Any exclusions should be made clear to you in your plan’s description of mental health benefits. If you are uncertain ask your insurance company.  According to NAMI, these are likely signs that a health plan may be violating parity requirements:

  1. Higher costs or fewer visits for mental health services than for other kinds of health care.
  2. Having to call and get permission to get mental health care covered, but not for other types of health care.
  3. Getting denied mental health services because they were not considered “medically necessary,” but the plan does not answer a request for the medical necessity criteria they use.
  4. Inability to find any in-network mental health providers that are taking new patients, but can for other health care.
  5. The plan will not cover residential mental health or substance use treatment or intensive outpatient care, but they do for other health conditions.

If you think your plan has violated parity requirements, speak with a senior plan administrator. The reason for denials of coverage must be made available by your insurance company upon request. If your treatment is denied and you disagree, contact your plan’s customer relations division right away (you will likely need to ask for a senior staff member). You may file a written formal appeal (ask your plan for details) or use NAMI’s template letters if your informal attempts are not successful.

Beware: A lot of health-insurance plans have what are called “phantom networks” — they’ll claim to cover your needs, but fall short when you try to make an appointment with a real human. A health-insurance company will send you a long list of providers, which will look impressive at first, but then when you try to call them, you’ll find out that they don’t actually exist — they retired, they stopped taking insurance, or they aren’t taking new patients. If the providers that are offered have a months-long waiting list, or they’ve moved to a different area, it’s technically fraud on the insurance company’s part. You can report them to a state regulatory body.

The American Psychological Association has created an excellent and informative guide to mental health insurance benefits for consumers. Please view a PDF of that guide here.

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Patients report that mental-health claims are denied more frequently than medical ones. If that happens to you, appeal to your insurer. You can find sample letters in the National Council of Behavioral Health’s parity toolkit.

You may also want to hire a billing advocate to help (they’ll charge a fee or a percent of what they recoup on your behalf). The Alliance of Claims Assistance Professionals has a search tool that lets you look up claims professionals by state. Medical Billing Advocates of America is a nationwide billing advocate.

Don’t overlook government help. The U.S. Department of Health and Human Services has a new website to help consumers who need assistance with mental-health or addiction coverage.

How to Appeal a Health Insurance Denial
This helpful guide from the Wall Street Journal offers a strategy for challenging your insurance company when you believe they have erroneously denied your claim.

New York Times Magazine Article: How to Afford Mental Health Care
Since Election Day 2016, the prospect of affordable mental health care is looking about as grim as women’s physical health care. With the future of the Affordable Care Act on shaky ground, the odds of getting coverage for psychological needs (and much more) may veer into dodgy territory as soon as Trump takes office. Read this informative article with links, advice, and tips, here:

60 Minutes Broadcast: When insurance companies deny the mentally ill the treatment their doctors prescribe, seriously ill people are often discharged, and can be a danger to themselves or others. The following link contains the rebroadcast and script from “Denied” which aired on December 14, 2014, and was rebroadcast on August 2, 2015. 60 Minutesfound that the vast majority of mental health claims are routine but the insurance industry aggressively reviews the cost of chronic cases. Long-term care for mental health is often denied by insurance company doctors who never see the patient. As a result, some seriously ill patients are discharged from hospitals over the objections of psychiatrists who warn that someone may die. In fact, the young woman in this broadcast did die when her insurer refused to continue her treatment.

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In the United States, there are for-profit hospitals and non-profit hospitals. Most hospitals in the US are non-profit hospitals. This means they are not allowed to make profits in the same manner that a business would. Hospitals often charge insurance companies lower medical rates than they charge the general public. This results in the public paying higher medical costs than the insurance companies.

The Affordable Care Act (ACA), enacted March 23, 2010, added new requirements that hospital organizations must satisfy in order to keep their nonprofit status.  These new requirements continue the IRS focus on the activities and policies of tax-exempt hospitals and the implication that tax-exempt hospitals must be required to “justify” their tax-exempt status, especially with regard to serving patients unable to pay for the costs of their medical care. IRS Rule 501(r) that takes effect as early as January 1, 2016 not only adds specific requirements for hospitals to qualify for tax-exempt status, it adds restrictions for how they can pursue payment for care provided.  Specifically, section 501(r) states that individuals must be charged the same rate or less than the insurance industry. To charge people more then insurance is engaging in profit makingThe amounts billed to patients without insurance must not exceed the amounts generally billed to individuals who have insurance or less for specific services. The most an individual can be charged is no more than the hospitals HMO would be charged.

The 501(r) rules primarily govern how hospitals can bill patients for medically necessitated emergency care and has four main components:

•   501(r)(3) – Establishes the requirement to conduct a Community Health Needs Assessment (CHNA)

•   501(r)(4) – Governs financial assistance policies (FAP)

•   501(r)(5) – Sets limits on charges and defines average general billing (AGB) and methodologies for calculating the limitations

•   501(r)(6) – Sets communication requirements, timetables and restrictions for billing and collections.

Hospital organizations must comply with all four components to qualify for tax-exempt status.


Parents For Care
Parents for Care is an organization for care givers of the seriously mentally ill. It offers support, friendship, and education to the families of those suffering serious psychiatric disorders such as schizophrenia, bipolar disorder, major depression or depressive disorders, and PTSD. GoFundMe is used to award small grants to families struggling to stay afloat financially while dealing with the demands of care giving. Every penny of every donation goes toward families of those with serious mental illnesses in the form of small grants and products to help those who find themselves in financial straits while caring for a loved one with mental illness. Parents For Care’s popular monthly support meeting for care givers is accessible both in person and via Skype, with educational topics and a chance to meet other care givers who can support you in the demands you face assisting your family.

The Partnership for Prescription Assistance can help qualifying patients without prescription drug coverage get the medicines they need through the program that is right for them. Many will get their medications free or nearly free. For more information, visit or call 1-888-477-2669.

Blink Health:  Blink Health is the new way for all Americans to save on their prescriptions. Everyone now has access to one, low negotiated price on over 15,000 medications including most mental health prescriptions. Simply pay online before you pick up at your pharmacy to save up to 95%.  Having insurance doesn’t mean you pay the lowest price. When the Blink Price beats your copay, pay with Blink Health instead. If you have multiple prescriptions, you can use Blink to pay for some, or all of them at your pharmacy.  With Blink, even if you’re uninsured, you pay one low price online and pick up at any pharmacy. New users enjoy $5.00 off at checkout!

At GoodRx.comyou can search by drug name to find the lowest prices at pharmacies in your area, plus find coupons. is a national nonprofit organization that offers free information on programs that help people who can’t afford their medications (or other health-care costs).

The comprehensive database at lists patient assistance programs set up by drug companies for those who have trouble affording their medications.

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Utah Disability Law Center
The Disability Law Center (DLC) is a private, non-profit organization designated by the governor as Utah’s Protection and Advocacy (P&A) agency.  Its mission is to enforce and strengthen laws that protect the opportunities, choices and legal rights of Utahns with disabilities.

Match & Farnsworth LLP – Social Security Disability Attorneys
Their office can help you when you have become mentally or physically disabled and need to get benefits including disability insurance and SSI payments. Because they only handle Social Security Disability claims, they have the tools necessary to successfully appeal your case.  Read about the Disability and Special Needs Trust processes here:

  • Administrative Law Courts: Our lawyers are expert at handling cases at the Administrative Law Court level. If you are involved in a dispute concerning the exercise of public power, please give us a call.
  • Appeals: If your previous claim or case has been denied, give our Social Security attorneys in Salt Lake City, UT a call. We can reevaluate your case and help you apply for an appeal.
  • Applications: Our attorneys are also adept in the application process for insurance and Social Security claims. Please contact us for more information.
  • Disability Benefits: Our Social Security attorneys are the best in the game when it comes to helping you or your loved one obtain the disability benefits you need and deserve.
  • Disability Insurance: Applying for Disability Insurance can be a complicated process. Give our Social Security attorneys a call to get the guidance you need.
  • Federal Court: If your case has been taken to Federal Court, give us a call right away. Our experienced and knowledgeable Social Security attorneys will help you build your case.
  • Hearings: We’ll help you prepare for your court hearing and make sure that your rights are protected.
  • Social Security Disability: If you’re applying for Social Security disability insurance, give Match and Farnsworth a call! Our Social Security attorneys have experience in the field and know what it takes to get the process started. We’ll see your claim through from start to finish.
  • Supplemental Security Income (SSI): If you or a loved one are low-income and 65 years or older, blind, or disabled, you may be eligible for SSI. Contact our Social Security attorneys for more information and begin building your claim.

Match & Farnsworth Disability Attorneys will offer you a free initial consultation to discuss the merits of your case.

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