If your child or teen needs mental health or behavioral health treatment you may be asking how you will pay for it? This article explains some of your options.

Private Insurance 

If your family is covered by private health insurance, either through an employer or Healthcare.gov, your health plan should cover the cost of therapy and prescription medications. As required by the Affordable Care Act, most private insurance plans are required to cover mental health and substance abuse services at the same level as other medical services and federal mental health parity laws. 

Learn More: Mental health and substance abuse health coverage options | HealthCare.gov

Be aware that private, self-insured plans are not required to cover these services. Check with your employee benefits department to make sure you have coverage. Also, while most private insurance plans can’t deny paying for mental health or substance-abuse services, they can limit the number of providers that are covered. For example, private insurance may only cover providers in their network. They can also limit the total number of provider visits per year. 

When paying for services, private insurance will still require you to be responsible for deductibles, your up-front cost before the plan starts covering any medical services. And if they are part of your plan, copays or coinsurance, a set amount per visit or percent of the bill you are responsible for paying. 

Will My Provider or Service be Covered? 

Start by calling your health plan’s members services department to verify that the provider will be covered under your plan. Have your member identification available as well as the name and address of the provider, the type of treatment and the number of visits recommended. 

You can learn more by reviewing your written benefits summary, called the Summary of Benefits and Coverage (SBC).If you don’t have a copy, your health plan can mail, email or tell you how to find it online. If you are starting the process of finding a provider, review your plan’s network of providers and preferred clinics. 

Private Pay 

Some therapists or other mental health providers do not accept private insurance or Medicaid. Clients are billed directly for services. However, these providers often work with families to ensure that the services are affordable. For example, they may have sliding fee scales (bills are based on your family’s income or ability to pay) or bills can be paid over a number of months. Before your child is seen, it may be helpful to discuss payment options with the provider or their billing staff. 

Wisconsin Medicaid / Medicaid-Funded Programs

If your child is enrolled in Wisconsin Medicaid, also called BadgerCare, MA and Katie Beckett, recommended mental health, behavioral health or related services may be a covered benefit. Contact ForwardHealth member services at (800)362-3002 for answers about services and limits on coverage. The treating mental health provider may also need to submit a prior authorization (PA) request before Medicaid will cover the service. If your child has been referred to a provider or program it is important to ask if Medicaid is accepted before starting treatment. 

What if my child is not enrolled in Medicaid? Could they qualify based on a mental health or behavioral health diagnosis? 

Yes! A child may be eligible for Medicaid based on their mental health or behavioral health condition. An evaluation must be completed, and a disability determination is required. Contact your County Human Services Department or call Wisconsin Wayfinder at (877)947-2929 to learn more.

Medicaid-Funded Programs for Children with Complex Behavioral Health Needs

Children who are involved in multiple systems like child welfare, mental health services, special education, juvenile justice and may also have a developmental disability, may be eligible for Coordinated Services Team (CST). These programs are county administered but are covered by Medicaid.

Learn More: www.dhs.wisconsin.gov/cst/index.htm

A Medicaid Coverage Option: HealthCheck Other Services (HCOS)

HealthCheck Other Services is a way for those covered by Medicaid to access mental health services when other coverage options are not available. HCOS requires your child’s doctor to complete a HealthCheck exam (called a screening) that indicates that mental health or behavioral health services are medically necessary. See the Family Voices Medicaid: HealthCheck Other Services resource.  

Children’s Long-Term Support (CLTS) Program:

The CLTS Program (dhs.wisconsin.gov/clts/index.htm) provides flexible Medicaid funding for children living with their families, including those with a severe emotional disability. CLTS can cover many programs and services for children. See the Family Voices CLTS series at familyvoiceswi.org/resource-library. 

Find Support for Your Family

Wisconsin Family Ties at (800)422-7145 is a statewide nonprofit agency that offers advocacy and support for families who have a child with mental health challenges. Their Parent-Peer Specialists connect trained parents to families for support and offer resources and learning opportunities.  

INFORMATION AND RESOURCES

Wisconsin Wayfinder: Children’s Resource Network, 877-WiscWay (877)947-2929):  Wisconsin Wayfinder offers families one name and phone number to find services for children with special health care needs. Wayfinder connects you to a resource guide at one of the five Children’s Resource Centers in your area.