If you have health insurance through Kaiser Permanente and need to see a therapist weekly, a service that Kaiser does not currently offer, the first step is establishing that you have a Medical Necessity. According to Kaiser’s Utilization Review policy. “The determination of whether a service is medically necessary is based upon criteria that are consistent with sound critical principles and processes, which are reviewed and approved annually by the Plan.”
What does this mean to you as a client, who is having symptoms of depression, anxiety, fear or leaving your house, or any other mental health condition that is affecting your life? The State of California and the federal government require insurance companies to provide the same standard of care for mental health care that they do for physical health care. This is referred to as Mental Health Parity. If a cancer diagnosis would qualify you for residential medical care and rehabilitation, a diagnosis of an eating disorder you might qualify for the same level of care.
If you have a moderate to severe diagnosis that meets a DSM V criteria contained in the mental and behavioral disorders chapter, you automatically meet the Medical Necessity standard. The determination about what level of care is necessary is made by your provider. An insurance company may disagree, but it is the provider’s job to back up the diagnosis and make recommendations for treatment with clinical knowledge and evidence.
Parity diagnoses recognized by law include:
Dementia
Psychosis
Bipolar Disorder
Schizophrenia
Schizoaffective Disorder
Major Depression
Obsessive Compulsive Disorder
Panic Disorder
Agoraphobia
Pervasive Developmental Disorders or Autism
Anorexia Nervosa
Bulimia Nervosa
In the State of California, the following is also covered:
ADHD
If you have one of these diagnoses, then you have the right under federal and state law to have your treatment covered in a manner equal to your medical treatment.
As with all things concerning insurance, there are exclusions to the law. Exclusions include:
Your insurance policy is not full coverage, i.e., it excludes mental health care
Your insurance policy is through a company that has fewer than 50 employees.
This is a basic primer on your rights under Mental Health Parity. Remember that using this language with insurance companies is powerful. Informed consumers are better at advocating for themselves. We want all of our clients to have the knowledge to get what you need and deserve from your insurance plan.