But what most Georgia residents need to know about is the so-called “parity” provision, says Kaleb McMichen, a spokesperson for Speaker David Ralston, who was the lead sponsor for the legislation. This part of the law mandates that insurance companies cover mental health services the same as they do services for physical care. Treatments for substance abuse and addiction must also be treated the same as physical care.
Here’s an example of how it should work: say a person enrolled in an insurance plan has unlimited doctor visits for a chronic condition like diabetes. Then, under the law, that plan must also offer unlimited visits for a mental health condition such as depression or obsessive compulsive disorder.
Getting into the weeds of the new law
The new law went into effect July 1. As of that date, insurance companies must cover care that is “medically necessary.” But it’s important to point out that this isn’t a new thing, says Roland Behm, a board member for the Georgia Chapter of the American Foundation for Suicide Prevention.
National law already requires that most health insurance plans treat mental health and substance abuse the same as other medical care. But a lot of companies find ways to skirt the law.
This new law in Georgia gives a definition of what is “medically necessary” to include the “generally accepted standards of mental health or substance abuse disorder care,” so there is no gray area.
The new law gives much less leeway to insurance companies to deny mental health coverage arbitrarily. The new law favors the judgment of the mental health professional treating the patient.
If an insurance company seeks to deny mental health coverage, the denial must be based on standards that are generally recognized by mental health professionals, not guidelines developed by or on behalf of the insurance company.
How can a person make sure that their mental health condition is being treated the same as a physical condition?
The biggest change that insured Georgians should expect to see now is insurance companies offering many more mental health and substance abuse professionals. But that could take some time, and Georgia residents might need to to file complaints with the state to spur change.
There will be several “very common red flags” that an insurance company is not following this new law, says Eve Byrd, director of the Carter Center’s Mental Health Program. They include, but aren’t limited to the following:
- A person cannot find a mental health clinician who is “in-network,” which is when an insurance company pays for the treatment.
- The number of treatments or visits for mental health or substance abuse services are limited in a way that other health care visits are not.
- A person has to call and get permission in order to have their mental health care covered, but they don’t have to do so for other types of health care.
Are there any loopholes or ways insurers will try to deny this treatment that Georgia residents should look out for?
Byrd, at the Carter Center, said to watch out for being denied a service on the grounds that it is “not medically necessary,” particularly when the mental health clinician is recommending that the treatment is needed.
If I’ve been receiving mental health services but paying for them myself, what do I need to do now to get them covered by insurance?
The answer to this is potentially a multi-step process says Behm, who serves on the board for the Georgia Chapter of the American Foundation for Suicide Prevention.
First, ask if your provider is in-network. If the provider isn’t in network, then find in-network behavioral health care providers, and contact them to see if they are taking new patients.
If you can’t find a provider that works, contact the insurance company and ask them to find a provider. Another alternative is to suggest the insurance company consider a single-case agreement, which would cover medically necessary treatments as if the provider were in-network
If the company is unable to produce an alternative provider or offer you a single-case agreement, then follow through with filling a complaint to the state.
What’s the process an insured Georgian can follow if the law is not being followed?
First, call your insurance company and dispute any denials for care or unexpected charges. While doing so, keep meticulous records of each communication with an insurance company regarding a dispute, like noting the name of the person you spoke with, the date of the call and a summary of the conversation you had.
If you can’t reach a resolution with your insurance company, file a complaint against your private insurer through the Consumer Services Division within the state’s Office of the Insurance Commissioner.
Those complaints can be filed online here. There are clear step-by-step guidelines for how to file a complaint.
For Medicaid enrollees, there is an internal appeal process that is unique to each Medicaid plan. If a person is unhappy with the decision, they can file an appeal with the Office of State Administrative Hearings.
The Atlanta Journal-Constitution is part of the Mental Health Parity Collaborative, a group of newsrooms that are covering challenges and solutions to accessing mental health care in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania, and Texas.