If your child or teen needs mental health or behavioral health treatment services one of the first questions you might ask is how will I pay for it?
If your family is covered by private health insurance, your health plan should cover the cost of therapy and prescription medications.
Most private insurance plans are now required to cover mental health and substance abuse services at the same level as other medical services, as required by the Affordable Care Act. Be aware that private self- insured plans don’t have to cover these services, so check with your employee benefits department. Also, while most private insurance plans can’t deny paying for mental health or substance abuse services, they can limit which providers are covered (for example, only providers in their network) and the total number of visits per year.
You will be responsible for deductibles (your up-front cost before the plan starts covering any medical services) and copays or coinsurance (a set amount per visit or percent of the bill you are responsible for paying).
How Do I Find Out if a Specific Provider or Service Will 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 also 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 send you another. It may also be available online. If you are starting the process of finding a provider, review your plan’s Network of Providers and preferred clinics.
Some therapists or other mental health providers do not accept private insurance or Medicaid. Clients are billed directly for services. However, many providers will 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 time. Before your child is seen, it may be helpful to discuss payment options with the provider or their billing staff.
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. Forward Health member services at 1.800.362.3002 can answer questions about the type of services and limits on coverage. The treating mental health provider may need to submit a prior authorization (PA) request in order for Medicaid to cover the services (see the Family Voices fact sheet on PAs to learn more). If your child has been referred to a provider or program it is important to ask if Medicaid is accepted.
What if my child is not enrolled in Medicaid? Could he or she 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 a Regional Center for Children and Youth with Special Health Care Needs to learn more.
HealthCheck Other Services (HCOS) – A Medicaid Coverage Option 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 annual exam (called a screening) that indicates that mental health or behavioral health services are medically necessary. To learn more contact Wisconsin Family Ties at 1.800.422.7145.
Children’s Long-Term Support (CLTS) Waivers
The Children’s Long-Term Support (CLTS) Medicaid Waivers (dhs.wisconsin.gov/clts/index.htm) provide flexible Medicaid funding for children living with their families who need a certain level of care in one of three areas of disability: physical disability, developmental disability and severe emotional disturbance (SED). CLTS funds can be used for supports and services not covered by your private insurance or Medicaid card. Examples include home medications to keep your child safe, a social skills class or respite.
Your county CLTS agency will work with your family to create an individual service plan and find the right programs and supports for your child. To qualify, a functional screen will be completed (see the Family Voices fact sheet for more details) and your child must meet a “psychiatric hospital level of care” need. Contact a Regional Center or Well Badger to learn more about CLTS waivers.