Understanding My Insurance and Benefits

How do I find an in-network provider?

Usually, on the back of your insurance card there is a specific number to call for mental health care. If there is not a specific number then call the customer service number and tell them you need a mental health referral.

Most managed care companies have a computer database that is used to find in-network providers in your area. Using your zip code most often does this. If you are willing to travel outside your zip code be sure to let them know and they will expand the search area.

When you call the provider, be sure to ask if they are accepting new patients and ask if they are still a provider for your insurance. There are frequent changes in provider status and your insurance company’s database may not be current.

Can I request a specific provider?

Yes, as long as they are on your provider list. You can ask the customer service representative to check for specific names on the provider list.

What are my benefit limitations?

Your benefit limitations are specified in your policy’s Explanation of Benefits (EOB) document, which is part of the paperwork you received when you first enrolled in the insurance plan. You can also call the insurance company. Usually the customer service representative can tell you how many visits of outpatient therapy your plan provides as well as inpatient care limits. They can also tell you what your co-pay will be per session. Be advised, all policies have limits, however, for severe cases of mental disorders you may be able to extend your benefits. Ask to speak with a clinician or supervisor if you have reached your plan limits and need ongoing care.

Will a managed care company provide the type of service I request?

People sometimes feel that they do not receive the care they want or need and blame the managed care company. The function of a managed care company is to manage the financial risk for your insurance company. Consequently, they often approve less expensive services before authorizing more expensive care. For example, they may authorize a partial hospital program rather than in-patient care if they believe this will best help your child.

What if I am unsure if my plan offers mental health and substance abuse benefits?
  • Contact your health insurer directly (There should be a phone number on the back of your insurance card.)
  • Contact your insurance agent
  • Contact your employer’s human resource office

Mental Health Coverage Chart

The chart here may help you determine if your plan is required to offer mental health and substance use disorder benefits and if it is required to cover those benefits similarly to other health benefits.

What if my child has an emergency, after normal business hours?

If your child needs emergency hospital care, call 911 or go to the hospital immediately and call the Cincinnati Children’s Psychiatric Intake Response Center (513-636-4124) on the way. The hospital staff will contact your insurance company for you. Many managed care companies have after hours staff to manage inpatient admissions (see your insurance card for contact information).

Understanding Plan Costs

How can I understand the costs associated with my plan?

Just like doctor visits, prescription drugs, physical therapy, etc., your mental health coverage is subjected to copays, coinsurance, deductibles, and out of pocket costs.

  • Co-payment= the dollar amount the patient is expected to pay at the time of service
  • Deductible= the amount you pay for health care expenses before insurance covers the costs. Typically, there would be an annual deductible amount.
  • Co-insurance= usually a percentage of the total cost you are responsible for after the services have been provided.

You can check the estimated cost of your out-of-pocket expenses by checking your summary of benefits and coverage in your insurance paperwork or by contacting your insurer directly.

What if I don’t know if my mental health conditions are covered?

Federal and state mental health laws do not provide a specific definition of what mental health and substance use disorder benefits/services must be covered in a health plan. However, coverage provided for physical and mental health/ substance use disorder benefits should be similar, and examples include:

  • Inpatient – If a plan covers a medically managed hospital stay for a medical condition such as a seizure disorder, then a medically managed stay for active withdrawal and stabilization for a mental health condition should be similarly covered.
  • Outpatient – If a plan covers an office visit to the cardiologist, it should also cover an office visit to the psychiatrist.
  • Emergency Care – If a plan covers emergency treatment for a broken arm, it should also cover emergency treatment after a suicide threat or for an unintended overdose.

Prescription Drugs – If a plan covers maintenance medication for diabetes, it should similarly cover maintenance medication for depression and medicated assisted therapies for addiction.

Disagreements or Complaints

What if my my child's doctor says they need to be in the hospital for their mental health condition, but the insurance company says no?

You have the right to appeal any decision made by your insurance company or their managed care company. Ask to speak with a supervisor and explain to them that you are requesting an immediate appeal. They will explain the process to you. A psychiatrist who will make an initial appeal determination often reviews the decision.

I am frustrated with my managed care company, what can I do?

Call your company and ask to speak with a supervisor. Try to be nice and explain your reason for being upset. Have an idea about what would solve your dilemma and ask for this. Be prepared to ask for the supervisor’s supervisor.

What do I do if I want to file a complaint?

If you have a question or concern about your mental health/ substance abuse benefits and are unable to resolve a complaint with your insurer you can file a complaint with the Ohio Department of Insurance’s Consumer Services Division (CSD). When filing a complaint, the CSD will determine if your health plan handled your issue appropriately and within the terms of the policy or certificate of coverage.

When filing a complaint, have the following information handy:

  • The name of your health plan
  • Your policy number and group number (found on your insurance card)
  • Description of what happened and who was involved
  • If the complaint involves dependent under family coverage, identify the person named on the policy
  • Include any corresponding letters you have that the company has sent you related to the dispute

You can file a complaint by:

Ohio

Online complaint form: https://gateway.insurance.ohio.gov/UI/ODI.CS.Public.UI/Complaint.mvc/DisplayConsumerComplaintForm

Emailing Consumer.Complaint@Insurance.Ohio.gov

Contacting ODI’s consumer services at 800-686-1526

Kentucky

Online complaint form: https://insurance.ky.gov/ppc/forms/Online_Complaint.aspx

Printable form: https://insurance.ky.gov/PPC/Documents/ConsComplaintWithInstr052019.pdf  –Mail to: Kentucky Department of Insurance Division of Consumer Protection P.O. Box 517, Frankfort, KY 40602

Indiana

Complaint form: https://indianaattorneygeneral.secure.force.com/ConsumerComplaintForm

Printable form: https://www.in.gov/attorneygeneral/files/Printable%20Consumer%20Complaint%20Form.pdf

Mail to: Consumer Protection Division Office of the Indiana Attorney General 302 W. Washington St., 5th Floor Indianapolis, IN 46204

How do I appeal a claim denial?

If you disagree with a decision made by your health plan regarding any claim denial or a reduction of benefits you have the right to appeal that decision under Ohio law. This may include benefit denials, prior authorization denials, and reductions in the length of stay of an inpatient facility. To begin the process, notify your insurance company that you’d like to appeal. The initial appeal is conducted by the insurer. If your insurer upholds its original determination and you would like the situation looked into further, tell your insurance company that you want to appeal to the Ohio Department of Insurance (external review). Then, they will send all the paperwork to the department to begin that process. Once the external review is completed, you will be notified of a final decision.

What other problems could I face when trying to secure mental health services for my child?

Sometimes insurance companies refer consumers to mental health providers who are either not accepting any new patients, or who are not accepting patients from the consumer’s insurance group. This problem frequently occurs if an insurance company has not updated its mental health provider database.

There are several ways to deal with this frustration. First, when you call a mental health provider, always ask up front if they are accepting new patients and whether they are a provider for your insurance group. Second, always try calling all of the mental health providers given to you by your insurance carrier – this should result in several possible matches. If all else fails, call your insurance company and ask to speak with a supervisor to deal with the problem.

Most states also have an Insurance Board that will field complaints about companies doing business in the state.

Ohio Insurance Board
1-800-686-1526
www.insurance.ohio.gov
Kentucky Insurance Board
1-800-595-6053
insurance.ky.gov
Indiana Insurance Board
1-800-622-4461
www.in.gov/idoi/