If you or a loved one is battling mental health and/or substance abuse issues, it can be difficult to know when and where to get help. Rest assured, you are not alone.
Navigating the managed care system can be overwhelming and confusing. There are several levels of care to consider, in-network and out-of-network providers, and specific treatments.
Here is everything you need to know about Blue Cross Blue Shield rehab coverage for behavioral health which is the umbrella term for mental health and substance abuse treatment.
Mental Health Parity is a Federal law passed in 2008 so insurance companies can’t discriminate against members with mental health and substance abuse disorders. The rules were implemented in 2013, and this law is your biggest advocate for getting the treatment you need.
The law states that group health plans with more than 50 members must provide the same care for mental health and substance abuse disorders as for physical medical conditions. For example, if your BCBS plan has unlimited outpatient visits for diabetes, it must also have unlimited outpatient visits for depression.
Be aware that this does not mean that you get unlimited services at every level of care for behavioral health treatment. What is covered depends on the specific language in your plan.
Each Blue Cross Blue Shield insurance plan has a unique language that states what they will and will not cover, on both the medical side and the behavioral health side.
Again, with mental health parity, if something is covered medically, the equivalent must be covered for behavioral health. If there is a limit on medical coverage, there may also be a limit on behavioral health.
The best way to find out what is covered on your BCBS plan is to call the customer care number on the back of your insurance card.
Network status can get a bit tricky to understand. Certain providers will contract with Blue Cross Blue Shield at specific, usually discounted rates. These are considered in-network providers.
This doesn’t mean that you can’t go to out-of-network or non-contracting providers. Depending on your plan’s specific language, you may be able to go to an out-of-network provider, but you may be balanced billed for what BCBS does not cover.
To navigate this, you will want to call customer care and the treatment provider to confirm the network status. There should be transparency on both ends of exactly what you will end up paying.
Behavioral Health includes mental health, substance abuse, and dual diagnosis (disorders of both mental health and substance abuse). There are inpatient and outpatient levels of care for each category.
For mental health, the levels of care are inpatient psychiatric hospitalization, treatment at a residential treatment facility (RTC), partial hospitalization (PHP), intensive outpatient (IOP), and outpatient treatment.
In addition to traditional outpatient appointments like counseling and medication management, other therapies such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) can be done, inpatient or outpatient.
The levels of care for substance abuse are inpatient detox in a hospital setting, subacute detox in a residential care facility, residential treatment (RTC), partial hospitalization (PHP), intensive outpatient (IOP), and outpatient treatment. Another treatment that may be utilized with substance abuse disorders is called medication-assisted treatment (MAT) which can be provided at any level of care.
Some treatment providers specialize in dual diagnosis and may have a combination of any of the levels of care for mental health and substance abuse.
All care covered by Blue Cross Blue Shield, whether medical or behavioral health, is based on medical necessity. Insurance companies use third-party objective medical necessity tools based on symptoms to determine medical necessity and level of care.
The treatment provider will also know the criteria for medical necessity at each level of care. When you seek treatment, you will usually be given an intake assessment to determine your appropriate level of care, which is what Blue Cross Blue Shield should cover.
Depending on your BCBS plan language, some levels of care may need to be pre-certified before starting treatment.
When possible, you should call customer care to see if you need pre-certification. Your treatment provider should also know this, and they are the ones who will obtain the pre-certification from Blue Cross Blue Shield.
The only exception is during a behavioral health emergency when someone is either suicidal, homicidal, actively psychotic, or having severe withdrawal symptoms from substances. In these cases, go straight to an inpatient facility or hospital, and your provider will sort it out for you.
Your Blue Cross Blue Shield plan should cover most medications if you are at an inpatient facility. Some medications may require pre-certification at outpatient levels of care, including PHP and IOP. This is something you should ask your provider about to check for you and pre-certify if necessary.
One thing to look for in a provider is that they have both a state license and national accreditation such as Joint Commission Certification (JCC). You also want to know what insurances are accepted; both in-network and out-of-network.
In addition to traditional therapies such as cognitive behavioral therapy (CBT) and medication management, many providers offer experiential treatments such as equine-assisted therapy, accelerated resolution therapy (ART), eye movement desensitization, and reprocessing (EMDR), and SoundPath Recovery.