Health Care Systems - What happens when there is a mental health or substance abuse problem?

Coverage of mental health and substance abuse problems varies widely from plan to plan. Just because the information booklet of a health care plan lists mental health and substance abuse care as covered expenses does not mean a consumer won't encounter difficulty. Some plans are more restrictive in reality than they are on paper and may involve a lot of outof-pocket costs.

Mental health and substance abuse are often carve outs (see page 147) from the rest of the health plan. The care may actually come from a different company with a whole other set of phone numbers and addresses, and another set of rules to learn. These plans decide which kind of medical professional will treat the patient, what medicine or testing is required and approved, whether the treatment will be inpatient or outpatient, and how many sessions are needed and allowed.


Experimental treatment is different from alternative treatment. Experimental or investigational treatments may very well be effective but are not yet considered standard treatment in the medical community. A practice could be termed experimental because

  • there is inadequate scientific evidence to support the treatment's effectiveness;
  • the treatment has not been found to be as safe or effective as the standard treatment; or
  • in the case of a prescription drug, the Food and Drug Administration has not yet approved the product.

If a patient has not succeeded with standard treatment, or no standard treatment is available, it could be worthwhile to investigate participating in a clinical trial. A clinical trial is an investigation into new treatment methods, materials, or procedures for a specific disease or condition. Clinical trials can give a patient access to state-of-the-art care before it is widely available. The treatment may not always be effective, but many patients who are suffering from serious conditions are willing to experiment.

Most health plans do not cover experimental treatments. The primary care physician or specialist supervising the treatment can help by submitting documentation to support the need for the experimental treatment. If the plan still denies coverage, the patient can submit a formal appeal.

Managed care organizations require that all mental health or substance abuse treatments, like all medical treatments, meet the test of medical necessity. There is the very real possibility that, in order to control costs, the managed care plan will first approve treatment that may not be sufficient for the patient. Health care consumers must be their own advocates. However, in cases of mental health or substance abuse problems, the instability caused by the condition may make this more difficult. If individuals cannot advocate for themselves, a family member may need to step in to ensure that the individual gets the care needed for recovery.

Sometimes consumers do not meet the requirements for medical necessity of mental health or substance abuse treatment. This means that the problems of some patients may not be viewed as worthy of treatment by their health care providers. For example, a person who is experiencing stress or grief may wish to seek counseling, but the health care plan may only provide for a few sessions. Other times, the consumer has to wait to be referred for services. Both can be frustrating scenarios when a person is in need. The smartest way to avoid these situations is to evaluate a health plan for mental health and substance abuse treatment coverage before it is needed.

Some questions to keep in mind when evaluating a health care plan for coverage of mental health issues:

  • Who are the mental health providers, and what are their qualifications?
  • How does one get information on mental health providers?
  • How many visits are covered by the plan? How many initial visits are allowed before the mental health provider must make the case that further treatment is medically necessary?
  • How does one schedule an appointment? Is a referral needed in advance? If so, who gives the referral, the primary care physician or someone else?
  • Does the plan offer rehabilitation coverage? What about substance abuse detoxification?
  • Does the plan have enough mental health providers so that waiting for an appointment is not an issue?
  • How much are the copayments and deductibles?

Mental health care is no different from the rest of managed care. There are many complex rules for getting care, and many of the rules center around the referral process. Not understanding the referral process in advance can add even more stress to a stressful situation. The referral will allow a certain number of visits or a certain length of time during which the referral is valid. If the referral runs out, a patient may have to work with the mental health provider and primary care physician to request extended treatment.

Choosing a mental health provider is as serious as choosing a primary care physician. A patient may be choosing from psychiatrists, psychologists, marriage and family therapists, clinical social workers, psychiatric nurses, and licensed professional counselors. The mental health provider devises a treatment plan and submits it to the managed care organization for approval. This is when it will be determined if mental health treatment is medically necessary.

Outpatient Care

Most mental health and substance abuse treatment will be delivered through outpatient care. Outpatient means that a patient will receive treatment during the day but will not live at the treatment center. As stated earlier, once a provider has been chosen, a treatment plan will be developed. A patient will be authorized for a certain number of visits in a specific length of time.

If therapists think patients need more time or more visits, they will complete the Patient Evaluation and Treatment plan before the authorized time runs out. Another decision will then be made by the managed care organization about whether to extend the treatment for more time or more visits.

Inpatient Care

Inpatient care, or hospitalization, is a difficult subject in managed care. Therapists may see that because the patient lives at the treatment center, inpatient care provides the best opportunity for treatment. The patient and family members may also believe that the hospital provides the safest environment for the patient. However, managed care organizations will generally push for outpatient care because it is less expensive. If inpatient care is approved, it will be approved for only a short amount of time in most cases.

If a patient and therapist feel strongly about having inpatient care, the therapist will have to fight for the patient to receive inpatient care, especially inpatient care beyond the initially approved time period. The outpatient therapist may be a different person from the inpatient therapist, but either can push the limits of the health plan to get the best treatment for the patient.

Common complaints about mental health treatment are:

  • denial of care;
  • excessive demands for personal patient information from the managed care organization;
  • untrained employees following rigid rules in denying treatment;
  • interruption of treatment; and
  • unclear, or even deceptive, statements about mental health benefits by the managed care organization.


It's not uncommon to disagree with a decision made by a health care plan. The complexities and restrictions of managed care call for people to learn how to advocate (support) for themselves. A person can challenge any bill or service problem. Problems can occur even when the rules and procedures are followed exactly. The first step is to file a grievance, or complaint. Grievance proceedings can be slow and long. A member's handbook will give information on how to file a grievance. The most important thing is for people to know their rights when it comes to their personal health care.

Some plans have very limited mental health benefits. When changing plans, continuity of care can become a problem. A patient may have been seeing a therapist for a period of time but, under a new plan, the therapist is not a part of the approved provider list. Sometimes the patient can continue with the therapist for a higher out-of-pocket cost. Sometimes the patient will be forced to change therapists.

User Contributions:

Comment about this article, ask questions, or add new information about this topic:


The Content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of Content found on the Website.