Health Insurance Coverage for Mental Health Services

Parent Q&A

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  • I have a young child with a severe mental health condition.  It started when she was 9 years old and she is now 14.  She has been in and out of school, however about every 6-8 months she has a relapse and I have trouble getting her care.  She is covered through Medi-cal and currently I am looking for a PHP (partial hospitalization program) where she can receive intensive mental health care services, counseling etc.  She is taking medication, however she still falls out of remission when she is stressed.   Currently, we are in a month long relapse and don't know what else to do.  She has been hospitalized seven times since she was diagnosed and still has not had any real life changing help; just crisis intervention,   several different medications, and some talk and play therapy. 

    I have been told Medi-cal does not cover PHP programs for adolescents.  I called around a few places to see if I could pay out of pocket and the price is approximately $1200 per day and the stay would be 8 weeks-not financially possible without losing everything we have.   The PHP coverage through Medi-cal is reserved for adults with issues such as substance abuse.  Seems a little odd.  Does anyone have any experience with this sort of situation.  This is my first time writing and I am trying to be a little discreet, but I would welcome any suggestions.   I have found that the mentally ill are seriously underserved, especially in this time of Covid.  I would like my daughter to have a chance at a somewhat normal life.  What I have been doing does not seem to be good enough; there has to me more help out there.  

    On another note,  I also been told that now is the time to get a conservatorship.  Any suggestions on who to contact. 

    Looking forward to some help

    Thank you

    I have an older teen on Medi-Cal and have also heard for many years that there is no PHP or IOP through Medi-Cal.  Have you thought about going through Mental Health ACCESS to request Therapeutic Behavioral Services (TBS) instead?  They provide in-home intensive treatment for a few months to try to heal an entrenched problem.  In the past I have requested up to 28 hours per week and ended up being granted 22 hours.  I recommend that you request it ASAP because there can be a long delay before services kick in and I believe the provider actually takes 30 days to simply observe before creating a Treatment Plan.

    Here are the phone numbers for Mental Health ACCESS:

    Alameda County:  1-800-491-9099

    Contra Costa County:  1-888-678-7277

    San Francisco:  (415) 255-3737

    Following up regarding conservatorship -- this is very difficult to obtain in California.  It is also a double-edged sword because if you have a young adult who is out and about in the community, perhaps not making good choices, then you will still be financially liable for any bad choices that they make if they are under conservatorship.  Some examples are:  stealing and damaging a car, driving while intoxicated, breaking into a building, vandalism, etc.  Your finances could be imperiled depending if your young adult is choosing a risky lifestyle.  It may  make sense for some families, but only if the young adult buys into a safe lifestyle.

    Dear Penelope:

      I am sorry to hear about your daughter's challenge.

     I have an adult son, who was diagnosed with a low-level of bipolar, at the age of 17--. Up until he reached 30, all was managed, without medication --he chose to bicycle and jog, stayed away from sugar and alcohol, stopped cigarettes, but then came the pandemic & once he started drinking again, but most importantly, vaping, his bipolar ups/downs became HIGH level--Today, that's where we are.  Husband & I turned to NAMI (National Alliance on Mental Illness)  .  Are you connected with the East Bay chapter of NAMI??  Classes are offered to friends/ family members--free of charge. Apart from the 'family to family' classes there are regular monthly meetings for family, friends and separate gatherings for the 'client'--yes, including children (sorry, I'm unsure how old the child must be).  Please reach out to them (located on Stannage in Albany). My experience is there  is a wealth of experience and know-how for getting help for yourself and for your loved one. 

       All the best!

    I am so sorry to hear the pain your child and family is in. I wish you all the best in navigating these issues. I recently researched therapists for my daughter and found this organization: Bay Area Clinical Associates ( They mention on their website that they are working toward being able to accept Medi-Cal. You could contact them to see how far along in the process they are.

    So sorry to hear about your daughter's challenges. My daughter has a complex set of mental health struggles and diagnoses, she has been hospitalized numerous times. Your daughter's school district should be a funding source. She will need an IEP for Emotional Disturbance. If you are interested in considering a residential program, the school district should cover the entire amount which will be around 13K-15K per month and will be a 10-18 month stay. The school district receives federal money for this.  Even if you decide not to go the residential route, it might be helpful to do some research and talk to a couple of programs to get an idea of what they provide and how it works. There are a lot of programs in Utah. A great resource for information is DREDF (Disability Rights Education and Defense Fund), they have an office in Berkeley and do most communication by phone. You will need a lawyer to set up a conservatorship, most lawyers will do an initial 20-30 minute phone call with you for free. Good Luck.

    I’m sorry to hear your daughter is struggling so much, I too have a teen daughter who is dealing with a serious mental illness and know acutely how hard it is to find appropriate help!  
    I don’t have any answers to your specific question but have 3 things to suggest that might be helpful.

    NAMI is a wonderful organization that offers support groups (currently weekly on zoom) and members may have recommendations. 

    Willows in the Wind is another support group for parents with kids who have mental health issues and addiction I think?

    There is a place with looking into called The Felton Institute. It’s only for early psychosis but offers ongoing support in a wraparound way. 

    I encourage you to get as much help as you can before she turns 18 and can refuse treatment.

    in case she is resistant, you may benefit from the book I’m Not Sick, I don’t Need Help by Xavier Amador. Look up his Ted talk about anosognosia. 

    lastly there is a group called FASMI who is working to push for better services and support for seriously mentally ill. There are many parents in this group who would understand though many have adult children.

    best of luck, I’m in it too and it’s awful, And COVID has made it monstrously worse. Wishing your family all the best!

    Hi, my daughter started having severe mental health problems around the same age. We don’t have medi-cal so I have no experience with that but might be able to help navigate. I have dealt with 4 hospitals, numerous therapists and inpatient and my insurance company. My daughter has been inpatient, IOP and PHP. Please feel free to email me (ask the moderator for my info). I’m happy to help. I found it was vital to have support as well. My daughter is now 19. 

    I am so sorry you are going through this and have run up against all of these financial barriers in mental health access. As a family physician myself, I know that partial programs are a rare resource, so this is not an easy world to navigate. Your Medi-Cal managed care plan should have a patient navigation service, and some counties also have a patient navigation service usually embedded in their county’s healthcare delivery system (ex. Alameda Health Services in Oakland). Within these systems you often find more robust support for mentl health, especially medical social workers experienced with Medi-Cal, because these systems care for most of the patients with severe mood and other paych disorders. Berkeley doesn’t have such a system, but I would imagine Lifelong FQHC system as similar support. Those most experienced at navigating this system are often academic child and adolescent psychiatry residency programs, where their attending physicians, residents and fellows are actively working in the outpatient, partial and inpatient settings. Thus, they know the criteria for admission, what is required to get the admission coveredc and the likely benefit for treatment at the various facilities. They may be able to arrange for a “direct admit” to a given program, where they place the admission orders from the clinic until the care of the child is assumed by the physician who is actually on service at the partial program or hospital.

    Hi, I'm sorry your family has been going through all of this. My daughter went through a local PHP virtually (Rogers) during COVID and it didn't really help. Hopefully they are starting to meet in person. You didn't mention the specialty area that your daughter needs help with so it's hare to see if the program we tried would help. I called SO many programs, so I understand your frustration.

    On another note - again, without knowing anything about your child, we have found a diagnoses called PANS and PANDAS which causes psychiatric illnesses and since you've tried so many things already and they haven't worked, I'm wondering if these diagnoses may be something you can look into as they have a different treatment.

    All the best.

    I sent your post to child psychiiatrist friends of mine, and I hope their responses might be helpful: 

    “This person needs to speak to the child’s psychiatrist. The referral to higher level of care would come from them. Most partials take Medicaid.”
    “Agree, talk with the kid’s psychiatrist, assuming she has one, as something underlying the relapse is not getting treated.  If she does not have one, now would be the time to get one or get a second opinion.  The parent may want to check through their insurance or the Psychology Today Therapist finder. This tool has  separate search capabilities for physician psychiatrists- I would not revommend a psych NPs for this patient. It can filter by location, insurance accepted, etc. Parent may also want to connect to the local chapter for NAMI for helping navigating resources in the area.  Agree with COVID not helping any of this.  Has made it much harder.”

    Hey Penelope,

    I am so sorry to hear you’re having such a difficult time. I am not a parent with experience in this area but I do know of this organization that may be able to be of help. They work with families who are having difficulty accessing appropriate mental health services for children.

    I am not sure if they will be helpful in your specific case but just figured I’d share the resource.

    Take care!

    Thank you so much to all who have taken the time to respond.  I feel better knowing there are individuals out there who have been through similar situations and who want to help.  I have to say my daughter has full support team.  She has had counseling at UCSF, UCSF Benioff, Pathways Girls Inc, TBS.  We currently have a county case worker,  she has an IEP with a 1:1 aide and a psychiatrist and therapist who are really awesome.  The problem is, my daughter finds it so hard to communicate.   I really feel her anxiety has gotten to a level that is unbearable for her.  She is showing signs of OCD and already has a diagnosis of " unspecified psychotic disorder" and anxiety disorder.   She continues to state that she has made a mistake and needs to know how to fix it.  This has gone on for 30 plus days.   

    On another note, I have gotten some more clarity on the insurance.  First,  we had a private plan with Kaiser before 2017 that made things a lot easier in terms of referral.  NOW,  We have Alameda Alliance, however, since we have been Kaiser Patients for so long,  they allowed us to continue with them as the primary provider.  Unfortunately, Kaiser only treats mild to moderate cases of psychosis so then we were referred to CHO.  However, at this point when I am trying to get her to Next Level of care, Kaiser is pointing the finger at Alameda Alliance,  Alameda Alliance has stated Beacon is in control.  After contacting Beacon, we were told to contact Kaiser again.  I asked our Pediatrician for a referral to an PHP or IOP an she went to the "chief of psychiatry" at Kaiser and he referred her back to Alameda Alliance.  At this point I don't know who covers what.  I am caught up in red tape and my daughter is paying the price.   I have registered with Nami and hope to find some help.  I have been to several meetings with them in the past, however I felt like no one could understand my situation because everyone suggested that a 9 year old could not become psychotic or schizophrenic.   The illness stared at age 9 with paranoia and delusions and has progressed from there.  She also got her first period about the same time.   Will keep trying....  I plan to file a grievance with Kaiser.  Any help would be appreciated

    Any help would be appreciated.   


    My heart goes out to you--so painful and difficult.  I asked a friend who has many years of child development/psychiatry practice in Sonoma. 

    She said  "If this were Sonoma County, I’d call the Sonoma County Mental Health Access Team. They provide services for kids on Medi-Cal (psychiatrist, case manager, wrap around services, some kids have gotten home visits and therapy).

    She needs to access all the outpatient services that can be offered….that might help and if not, if she can’t be served in a public school, sometimes the school will split the cost

    You kind of have to fail full outpatient services first before partial day or residential.  This woman needs an advocate!

    (Since it sounds like she hasn’t accessed that.)

    Hi Penelope -

    This sounds so hard. If you need help with the complaint process or figuring out who should cover what, I would suggest contacting the Health Consumer Center at Bay Area Legal Aid: Phone # is 1-855-693-7285. 

    Hi Penelope, I feel for your daughter! It sounds like she is struggling with a lot of different symptoms. I am a mental health professional working in Contra Costa County at a psychosis specialty program that also treats kids with at-risk symptoms including hallucinations and paranoia. It offers intensive services in line with Coordinated Specialty Care (CSC). I wonder if Alameda has a similar specialty psychosis program through the county. I know Kaiser has similar programs but not as fully fleshed out as our program. In terms of her current symptoms, that does sound like OCD, though her psychiatrist I’m sure would weigh in on that. If it is OCD, Rogers does have IOP and PHP programs focused specifically on OCD, but I believe they only take private insurance. Not sure if Kaiser has a contract with them or not. In general, my understanding is that you would have to switch to a private commercial health insurance to be covered for most IOP or PHP programs. At least in Contra Costa County, Medi-Cal doesn’t cover these kinds of programs and instead the county programs utilize wraparound, TBS, and other intensive outpatient services. Hope this is helpful…

    Hi Penelope, I’m sorry you’re having to deal with this. I am too. My daughter is almost 17 and is engaging in some drugs and a fair amount of nonsuicidal self harm. A lot of stuff I really don’t understand. This is especially frustrating when it’s so hard to get in touch with experts to consult. I have spent the last three weeks calling, inquiring and filling in Web forms. I have created a spreadsheet of the resources that I have contacted so far. And more that I have not contacted yet. It is by no means comprehensive, but I would be happy to share it with you. Please ask the  moderator to give you my email and I can send it to you in an attachment. 
    For the sake of my daughters privacy I have asked BPN to hide my user name. But I hope this doesn’t prevent them from sharing my contact info with you

  • Hello Berkeley Parents.

    We have a 17-year-old daughter who has been struggling with depression and anxiety, exacerbated by the school closure during the Covid shutdown. We have Kaiser as our health insurance carrier and we like them for routine and preventive care and I'd like to keep it for that reason.  However, their mental health care has been extremely disappointing (that is not even strong enough to express my feelings about that, but that's for another time and place).  We have found a non-Kaiser therapist who finally seems to be making a bit of a difference, but it is expensive to pay out of pocket.

    I have read on some of the thread about mental health about having to buy separate health insurance to pay for these service and I'm wondering if anyone has any recommendations  any particular health insurance carrier that I can get for my daughter specifically for this purpose? I would appreciate if if your recommendation is accompanied by your own experience with these insurance carriers.

    Thank you in advance for your help.

    I have not heard of an additional mental health insurance.  We have the same struggles with Kaiser for the same exact reason, and after a life time of being a member there I'm finally biting the bullet and switching to Cigna this open enrollment.  What I have done in the past is burn through our FSA account to pay out of pocket for non-Kaiser therapists.  Do you have and FSA or HSA option attached to your Kaiser insurance?

    My experience has been that I don't want to see any therapists that take insurance. We now build the cost of self-pay therapy into our monthly budget. We've had really bad experiences with in-network therapists and finally gave up. 

    I’m a longtime Kaiser patient and parent. KP is obligation to provide medically necessary mental health coverage. One should not have to get additional insurance. That said, mental health services from KP are abominable for the most part. I suggest you tell file a grievance with KP outlining the treatment your child needs. Ask you current outside therapist for help. State that you are not getting medical necessary treatment. Write that you want KP to pay for the out of network therapist. . Once you submit KP has 25 of so days to respond. They will say they are providing adequate care and will probably deny paying out of network. But ask! You can then appeal to the DMHC, a state agency that has doctors review claims. KP may be ordered to pay. Do this while you continue to get therapy that’s helping. 

       I cannot speak to your insurance plight. I'm sorry.  Our experience was & has been mostly without any insurance.  It's been tough.

       My adult son is diagnosed with bipolar --as well as epilepsy, learning challenges and PTSD.   Unfortunately, until he was in his 20's we were living in Texas at the time, with zero insurance, and very little support from the schools, from public services, etc.  We're here now, in California.  The services, mostly free, are so much better. 

      About your daughter, please check with the local branch of National Alliance on Mental Illness (NAMI). The East Bay meetings are held in a church in Albany. While your daughter isn't yet 18 (which seems to be the entry point) the staff know a lot about the resources in this area  --- for various degrees of mental challenges   

    You will learn a lot by attending one of  NAMI's support groups.  There you'll find parents who know the ropes quite well regarding what insurance has worked for them.

       Also, please give a call to the local Regional Center.  It's possible they can help or can refer you to someone who can.

       All the best to a dear mom who loves her daughter. 

    I don’t have a positive recommendation but avoid MHN. Hardly any providers are included. Most of the people on their list of supposed don’t accept the insurance when you call them. And hardly any of those who do have openings. So the idea of finding a good fit is out the window unless you are really lucky. 

    Have you asked Kaiser to pay for the therapist you found? Kaiser used to lay for outside therapists through Beacon insurance . You tell the Kaiser mental health felt you found a good therapist not in their department and they approve them, set you up with Beacon and you get a number of paid sessions that you have a copay for. I had 9 months of outside therapist treatment through Kaiser. If I had wanted more i think I could have had them. (Car accident trauma) Not sure now but I think the lawsuit their behavioral health department was subjected to resulted in this deal.  Pretty good. Only restriction is finding a therapist that takes Beacon. Never had the slightest push back from Kaiser. (About 2 or 3 years ago.) it went quickly and smoothly.

    Thank you for all your replies. I appreciated all of them.

    We are preparing to negotiate with Kaiser to at least foot some of the costs that we are having to incur with non-Kaiser therapist.  We are fortunate enough to have found one who was available and who seems to be helping my daughter, but $200 a pop, it adds up quickly. I am looking into switching to a UHC plan in the open enrollment if it doesn't work out with Kaiser. Her therapist would still be out-of-network, but they still reimburse. It' stressful enough trying to figure out the care she needs, I really don't need to have a stress of figuring out how to pay for it.

  • Hello Berkeley Parents.

    We have a 17-year-old daughter who has been struggling with depression and anxiety, exacerbated by the school closure during the Covid shutdown. We have Kaiser as our health insurance carrier and we like them for routine and preventive care and I'd like to keep it for that reason.  However, their mental health care has been extremely disappointing (that is not even strong enough to express my feelings about that, but that's for another time and place).  We have found a non-Kaiser therapist who finally seems to be making a bit of a difference, but it is expensive to pay out of pocket.

    I have read on some of the thread about mental health about having to buy separate health insurance to pay for these service and I'm wondering if anyone has any recommendations  any particular health insurance carrier that I can get for my daughter specifically for this purpose? I would appreciate if if your recommendation is accompanied by your own experience with these insurance carriers.

    Thank you in advance for your help.

    Hi, I am also with Kaiser and have found their mental health approach disappointing. I researched it further because it does not make sense. What I found out is that they cannot find nearly enough therapists to fill the tremendous need. 

    Following your post. I have the same feeling about Kaiser and we will change for Cigna, hoping it will be easier to find a therapist who cares for my 16yo who is struggling at school and loosing self confidence.

    I would be careful about switching to PPO to get better mental health care. We had both Cigna and Blue Shield during a 2-year break from Kaiser due to an employer change. Kaiser is bad, but the others were no better. With Cigna I had to call 35 therapists to find ONE that took their insurance (even though all 35 were listed on their site as preferred providers that took Cigna). I had a few sessions with that one person, a LCSW, but she was very new and inexperienced. With Blue Shield, it was even worse. I called over 30 and none actually took Blue Shield. They all said they would provide a "super bill", but the PPOs only pay a small fraction of those fees as they're considered out-of-network. I have heard some people have success getting Kaiser to pay for outside therapists, so that might be an option.

    We were with Anthem Blue Cross before switching to Kaiser in June. We couldn't find a therapist that was covered Anthem either so have been paying out of pocket for therapy both with Anthem & Kaiser. Psychiatry is covered, and we were lucky to find a great one with Kaiser (Dr. Westlake). Good luck!

  • We're choosing between Blue Shield of California and Kaiser (Oakland), and are entering into a therapy-heavy period for our daughter, ourselves, couples counseling and possibly family therapy. This question may be moot because every therapist I talk to doesn't take insurance anyway, but I'd like to hear your experiences with either insurer on this question (or any). 

    Thanks in advance!

    Definitely not Kaiser. We've paid a lot out of pocket for therapy because Kaiser is so bad.  We like a lot of what Kaiser provides, but I can't believe how awful their mental health services are. They really aren't interested in that type of long term care. They will throw antidepressants at you, check in with you once a month, and decide that's all you need. They even misdiagnosed me, but when I went to a psychologist I paid for out of pocket, I was finally diagnosed properly - in my 30s -  in the first session. And the treatment was finally appropriate and effective for what I was dealing with. Kaiser has a great Peds dept, I had my kids there, I like their women's health. Their pediatric orthopedists are great. Mental health? Absolutely horrible. 

    I suggest going to the websites of Blue Shield and Kaiser, do a provider search on each by web or by calling customer service, then call a few of the therapists that come up in the search to see if they are taking new patients and if so, schedule a phone or zoom consultation. We have Health Net and had absolutely no trouble at all via this process in finding several therapists to choose from.

    You are wise to think about this before entering a therapy-heavy period. My family has been in a therapy-heavy period for an extended time. We have a Blue Shield of CA High Deductible PPO plan. I have not been able to find therapists that accept insurance throughout all of our years in various combinations of individual, couples, and family therapy. That said, I have been able to get a small portion of our costs (~30%) reimbursed after paying out-of-pocket. It's not much, but every little bit helps.

    The claims for reimbursement take some time to set up and manage. Blue Shield has gotten better with the over the years and now has a straightforward online portal. Ask the therapists you are thinking of working with if they will provide a superbill for submittal to the insurance company (specific information is needed to file the claim). I keep a spreadsheet to track appointments, claims, and reimbursements, as occasionally Blue Shield will deny a claim for some reason (usually I've made an error inputting information) and not notify me. The good news is claims can be submitted within a year of the date of service, and I have not hit a max. coverage level despite years of therapy for various combination of family members. (Given the track record, perhaps the effectiveness of the therapy should be considered—ugh.)

    Good luck in finding good-fit therapists. They are worth the time, money, and effort. 

    I've been a member of Kaiser for 15 years and have found their mental health division to be almost non-existent. I've gotten referral to them and learned the wait time was ridiculous. For couples counseling, we were sent to a weekly workshop; it bore no resemblance to couples' therapy. I've continued to see my own therapist and have paid out-of-pocket for all of it. I hope someone has better news about therapy at Kaiser. Best of luck to you and your family. 

    I have not used Kaiser but everything I have heard from other parents in this situation is Kaiser really lacks resources for this. With BCBS you can choose from among many therapists around the area. That said many are booked and we have sometimes had to go outside of the network to find appropriate care. Many many therapists do not take insurance because they pay so little. Still I think BCBS is a better bet. 

    Kaiser does certain things very well-psychiatry/psychology is not one of them. I recommend Kaiser overall and you could certainly try a therapist there.  You might get lucky.  But my advice is to plan for private therapy.  Best of luck.

    Hi - I've been a Kaiser member for years, and I think there are many problems with their mental health services.  Mental health practitioners went on strike a couple of years back objecting to the understaffing.  There was also a recent article about their underhanded workarounds to poor response times to calls  - they hired an outside agency to answer first time calls, but then didn't essentially change access to first time appointments.  It's almost impossible to get regularly timed individual sessions with a counselor due to understaffing, and Kaiser's whole emphasis on mental health services is time-limited group referrals.  So you can go to a group for your depression, but even that is limited to a certain number of session (6 I think).  Definitely try other options - I've seen a private practice therapist for a long time due to their poor performance.

    Thank you so much for asking this question!  Blue Shield paid my therapist fairly easily.  Just google Kaiser Mental Health Care and you can find info about that.  But I am wondering too about this general question.

    We have Kaiser and it's not been good for therapy. They mainly offer groups, and can't really see anyone including kids for individual therapy more than once a month (and even then, appointments are frequently cancelled.) We were offered for our teen to see a private therapist but it turned out that no one actually takes the plan that Kaiser offers for that. We ended up paying out of pocket. I would check the exact coverage on Blue Shield but it may be better.

    Thanks everyone! Here and everywhere I'm hearing a universal thumbs down on Kaiser mental health services. I was leaning toward Kaiser because it was fantastic in SF when my daughter was little, but I now almost don't want to go with them on principle. Blue Shield PPO or HMO?

    If Blue Shield PPO is an option for you, I would suggest it. We have a Blue Shield HMO and have found the mental health provider options very limited—we pay out of pocket for private therapists. I'm not sure what the PPO offers, but usually you can get some kind of reimbursement for out-of-network providers.

    I see all the negative comments about Kaiser, and I was very surprised by my own experience. In the wake of a rather difficult illness, my Kaiser primary not only suggested that I consider treatment with Kaiser Behavioral Medicine, he made certain that I got an individual therapist. I have probably been lucky that things worked out for me, but it doesn’t seem to me that Kaiser Beh Medicine is always a hot mess.

    Hi, sorry for the late reply. We have been quite successful getting mental health care for our son at Kaiser Oakland. He was diagnosed at Kaiser with ADHD and OCD. The clinicians we've interacted with have been excellent overall and available. They have groups classes and individual sessions. I will say that we did go outside of Kaiser for weekly therapy that my son needed for less than a year. We were fortunate to be able to pay out of pocket for that. I have had Kaiser for years and have been quite happy with the care I and my family members have received there. 


    Responding to the person who recommended Blue Shield PPO. I am a member, and I am not happy. Most providers are not in the Blue Shield PPO network. You get "reimbursed" for "out of network providers", but since this is 30% of the "allowed" amount, it is rarely higher than $40-50 per session - at a time when therapists charge $150+ per session. You have to provide a superbill via mail and now online as well, that in 3 out of 4 cases somehow "gets lost" and never is processed. Their online portal lost 2 out of 3 claims I submitted- after I got a confirmation that they were received! Long story short - they do everything they can to not pay. The providers on their list are either so bad that you should not go there, or are completely booked. Sorry for being the bearer of bad news. 

  • Anyone have any advice on appealing a health insurance issue to the state? My child's mental health treatment was approved and then a few months in the insurance company denied payment because the practitioner is not fully licensed. I appealed to the company but they denied my appeal, now I want to appeal to the state but would love to get some advice first. If you would be willing to share any knowledge about the process or tips on a successful appeal I would be very appreciative. Thank you!

    I would suggest first confirming that you've exhausted the internal appeals available. There is often a second-tier appeal that is reviewed by a higher level person at the insurance company with a policy or regulatory role. Subsequently, you can appeal the coverage decisions by opening a case on the CDI website. While I've successfully challenged a number of coverage decisions, I don't have any experience getting coverage for unlicensed service providers. Generally speaking though, I would suggest that the persuasiveness of the arguments that you present in your appeal letter does have an impact on the outcome of your appeal.

    Is this an outpatient provider? I am an LCSW and was told when I was Pre licensed that MSW or AMFTs services are not always reimbursed by insurance. Many Pre licensed individuals offer sliding scales for this reason. I'm sorry this happened

    I’m sorry you’ve been struggling to get coverage for your child. The therapist should’ve been working under someone else’s license if he/she/ they are not licensed yet. Double check that there is no supervisor whose license can be used for billing. Otherwise, I don’t think you will win the appeal. If the therapist did not disclose that they are unlicensed you can ask for reimbursement from the therapist. There may be both legal and ethical issues involved.

    Make sure that you appeal the decision as high up as you can with the insurance provider, and also file a complaint with the provider. I filed a complaint with Kaiser and they immediately refunded my co-pay and bill for the service. 

    If that doesn't work, gather all the evidence you can of the treatment approval and then subsequent denial. Have paperwork from all the appeals and complaints, too. File an IMR here:

    I had success in appealing to the state once. An ambulance bill was sent to the wrong address due to a typo, so I never received it. Three years later, I moved and received the bill. Since this was after the 2 year window for filing claims, the insurance company, Blue Shield, denied my claim for the old bill. Appeals to Blue Shield were also denied. I filed an IMR. The decision was that while Blue Shield was within their right to deny the claim, it would be covered given the circumstances. 

    Good luck!

Archived Q&A and Reviews



A good insurance plan for Mental Health coverage?

Nov 2012

We have severe OCD in our immediate family, and right now we are insured with Kaiser. Their services are ill-equipped for severity of our needs, but they make it nearly impossible to be covered outside of their network. I wanted to know if anyone has had good experiences with other providers concerning mental health coverage (psychiatrists, psychologists). We are strapped for money and relying on parents, but can't NOT go the (truly helpful, non-kaiser) doctor right now. We are willing to change providers if there are good ones out there! Stay Healthy

A helpful resource for OCD treatment is the International OCD Foundation's website. They have a treatment provider database: Search options include the age of your family member (adult, teen, child), OCD treatment strategies requested (Exposure and Response Prevention, home visits), etc. The International OCD Foundation website lists OCD support groups and intensive treatment programs. Also, it has some information to help the family members of OCD sufferers think about how they can support their loved one without enabling the OCD itself - which can be a complicated balance. Best wishes, Jennifer

I used to have Cigna and it had good coverage of therapy and medication under their premium plan. There's still a deductible and I think overall coverage is limited to 30 visits/year, but it still saved me thousands of dollars and I got to see my preferred therapist. I'm now with Kaiser and paying out of pocket to stay with the same therapist and it HURTS financially. Good luck! Good insurance

I sympathize as I'm in your exact shoes. I'm the one with OCD and we have Kaiser. Their mental health services are beyond pathetic. They couldn't even diagnose me properly. I can't say enough bad things about that dept - for everything else, they've been fine. We had Health Net for a bit and I had no luck finding a decent CBT therapist who took the insurance. I finally had had enough and decided i had to pay out of pocket if i wanted to feel better. I walked into Mark Balabanis' office in Rockridge. He's expensive, but he's amazing. My OCD is SO much better - he gave me the tools I needed to combat the obsessive thoughts and compulsions. Kaiser just wanted to throw meds at me and sign me up for CBT group classes designed only to help those with generalized anxiety. I'll never be 100% since OCD isn't curable, but I'm at 85-90% and have been for about a year - and I'm med-free. Best of luck. Sympathetic

We have Anthem Blue Cross and they never give us any trouble with paying for therapy. Of course, they don't pay a large percentage but after talking with other friends it seems they may pay more than most. Good luck with this. Wendy


Listed therapists seem reluctant to accept our insurance

October 2008

Can anyone recommend a female therapist in Albany/Berkeley/El Cerrito that not only takes Blue Cross insurance...but doesn't mind taking it? I'm looking for someone who can see my teenage daughter. I took down several names from the Blue Cross WEB site and was surprised by the reception I got when I called them. The first one took three days to call me back. When she finally did, she left me a message saying she didn't take Blue Cross insurance and didn't know anyone who did. So, I called another. She called me back and left a message asking what times would work for my daughter, so I thought we were on the right track. I called her back with some possibilities and she returned that call to say that she didn't really have anything available that would work for those times (though I'd given many). I took her at her word and asked what she did have, saying that perhaps I'd have to take my daughter out of school to meet with her. She hesitated. She did come up with a time to suggest, that turned out to not work for us, but I got the distinct impression that she didn't really want to work with us. It's not me, honest! I was polite and accommodating, I promise. Has anyone else had this experience? Why do therapists list themselves with these insurance companies if they're not really interested in taking those patients? Has anyone had a good experience with Blue Cross insurance and a therapist and, if so, would you let me know who you used? Thanks. In Search of a BC Therapist

Your difficulty finding a therapist working on an insurance panel who has open slots is not an unusual problem. Many therapists work to get on insurance panels when they are early in their practices, and enjoy seeing the variety of people referred to them. However, to be in private practice, therapists need to make a fair amount of money to cover expenses, taxes and make a profit.

The reality is that being in a managed care panel means seeing clients at a much lower fee than they can charge for private fee for service. For this reason, many therapists put a limit on how many managed care cases they can have within their practice, and still have enough open slots to make a living.

What this also means is that prime time slots, like afternoons and early evenings for children and teenagers, are often reserved for fee for service clients, leaving fewer desirable time openings.

I can see why you may feel frustrated. It's reflective of a larger problem in the insurance industry, and there should be some way that therapists can communicate to their panels when they are full and not accepting new clients to help consumers avoid the frustration you are experiencing.

Another idea would be to call some place like The Psychotherapy Institute in Berkeley which has very well trained psychotherapy interns, who are very well supervised, and who see clients at lowered fees. Other lower fee community resources with therapy interns are Blue Oak Counseling Center and Jewish Family and Children's Services in Berkeley. anonymous

The anonymous post last week covered this answer well. I am a therapist who sees teens in private practice and recently decided after processing two clients with Blue Cross/Blue Shield that I am not taking any more, at least for the time being. The headache of the paperwork, spending hours (when we only have 10 min breaks) trying to get someone to resolve claims issues, and poor reimbursement rates are too problematic. This is unfortunate because some people can only afford therapy by using insurance. However, there are many private practice therapist, and low fee clinics that are willing to make therapy more affordable without going through insurance. You can ask the BC/BS providers if they would be willing get recommendations for names through BPN, or I also recommend The Psychotherapy Institute (adults and couples only), or Ann Martin Center (children) or WestCoast Children's Clinic for sliding scale therapy provided by supervised interns. Another way people reduce the financial strain is pay out of pocket and get reimbursed by their insurance (some plans will do this) or by an employer-based ''flex spending account'' that you put pre-tax wages into and then pull your reimbursement from. Anonymous therapist.

Insurance won't pay therapist - she wants me to pay

October 2005

Hi there, I have found myself in a situation with my daughters therapist that i dont know how to deal with.....the whole thing just makes me feel really uncomfortable and i need some outside perspective.

My daugter started seeing a therapist in March of this year. We are insured with Blue cross HMO and i found a MFT off their list of providers. I also DOUBLE checked with this therapist when we started that she was in fact a provider. She assured me that she was. So, fast forward to September. The therapist shows me a bill that she submitted and that was rejected for payment. That invoice only covered the first 6 sessions (she has gone once a week since march), it was for $300 and they rejected it. She asked me to call....which i did, and they said that she is NOT a provider. I got back to her.....she said she would call again and talk to them more, as she apperently has billed for other Blue cross HMO folks and is confused why she was rejected. At this point, they have not paid her for that first invoice, and im sure they wont for the months of visits that followed.

The problem is although she hasnt come out and said it clearly yet, i know that she thinks i should be responsible for a good chunk, if not all of the outstanding balance.

Where i come from is this: I found a therapist from the list spacifically because i cannot afford a private one, and whatever the reason...either she was dropped and dint know, or something, she confirmed to me that she was a provider. After that though, if i had known that they rejected her for that first bill i would have switched my daughter to another provider that was covered. The issue there is that she didnt send her first invoice for 5 months. So, we kept going (and thus racking up a bill) under the assuption that we were being covered.

I am willing to pay for some of the first bill..... i do feel really bad about the situation she is in. But, I really dont feel i should be responsible for the whole $300 ...nor any of the following invoices.

what do you think? thanks anon

I'm a therapist in private practice. Perhaps she is confusing Blue cross with Blue Shield. I believe one pays off-panel providers and one doesn't. Regardless, if I was the therapist for your daughter and this situation arose I would err on the side of the patient and not hold patient responsible. Also, waiting for 5 months to bill is not ethical--some ins. companies only give you 90-120 days to bill or they won't reimburse. I would be direct with this therapist about what you think is fair to you, and take it from there. Good luck. Another Therapist

I'm afraid you are going to be financially responsible for these bills. In future, the best source of information as far a which providers are currently contracted with any insurance company, is to contact that insurance company's Customer Service Department by phone directly yourself. Printed rosters are out of date as soon as they are printed, and individual practitioners (especially mental health, I find) are not always the most accurate source of information. Additionally, especially with mental health, services are routinely carved out by HMOs and separate vendors are used for this service (such as UBH, etc.). In such an instance, a therapist would need to be contracted with the mental health vendor, rather than the insurance company.

The therapist probably had you sign a waiver when services commenced, stating that if services turn out not to be covered, that you would be financially responsible for them. Although it is very poor billing practice (and poor financial management) for the therapist not to have billed you for five months, the reality is that if the provider is not contracted with whomever the designated mental health network is for your daughter, you are likely financially responsible for the service.

The best place for you to dispute this is with the health plan or mental health vendor, not with the provider. Good luck, and patient beware. Managed care expert

I suggest trying to work with your insurance company at this point, rather than worrying about what to pay the therapist. The therapist bills your insurance as a courtesy, but the insurance is the one making the decisions. Most insurance companies have a process in which you can contest a decision of theirs, and the rates of decision reversals can be surprisingly high! Most people just don't bother to go through the process. So, get all your ducks in a row (ie, copy of the insurance list you saw with your therapist's name on it) and call right away to start the process. Jennifer

Your daughter's therapist should know if she's been dropped as a network provider. She would have been notified by mail. I would call the number on the back of your card to find out what has happened so that you can have some clarity about how much responsibility each of you have in the matter. You said that you got her name off of a list. Was that the list from the Blue Cross website? Is it possible that she is a provider, but that the diagnosis is not covered? Your statements should have the reasons for non-payment clearly listed. In any case, it seems fair that you pay the first bill in full, 4-6 sessions, and then your co-pay ( ususally something like $15 per session ) for the remaining sessions because you would have been responsible for that amount anyway. Billing insurance companies can be confusing. They do make mistakes so it's important for you to advocate for yourself by having as much information as possible. To add to the confusion Blue Cross and Blue Shield seem to function as one company except in the state of CA. Annonymous Blue Cross therapist

This happened to me once, though not with a therapist, and I steadfastly refused to pay the bill. The office had clearly misstated their position (they'd said they were providers from a particular health plan when they weren't). As I recall, I think I also called the health plan, and they intervened. I would think, especially with a therapist, you'd want to feel trust that has now been clouded by this issue. They should not have waited 5 months before sending the first bill; that's just too long. Maybe the therapist is great, and the billing dept is just disorganized, but ultimately the doctor is in charge and should have an office that reflects the integrity you'd hope he/she has. br

I am an MFT, but don't have much experience dealing with insurance companies, so I hope others reply who do have that experience. I can see your point of view, and think that what you say makes sense. You saw this therapist because Blue Cross and the therapist said that she was a provider. It is not good business practice on the part of the therapist to not keep current with bills, say, billing at the end of the month. Showing a bill from 5 months prior, when this is different from the arrangement you entered does not sound like fair business practices. If you need advice on this, you could call the California Association of Marriage and Family Therapists, toll free at 888-89-CAMFT for advice on how to pursue this. Anon.

If the therapist was on your HMO list as a preferred provider, then that shouldn't be the reason for her not being reimbursed. Maybe the claim was denied because she waited 5 months to send in the bill. Many companies require that bills be submitted within a certain time frame - like 60 or 90 days. The other consideration is your informed consent. Did she verbally or in writing provide information about her office policies including fees and reimbursement in case of problems with the insureance company? Good Luck

Yes, I do agree that you shouldn't be responsible for the full amount. I would recommend that you explain to therapist exactly what you wrote in your posting, that you found a therapist from the list specifically because you cannot afford a private one. Explain to her that you are worried that the insurance will not cover it and it will create financial hardship for you to have to pay that amount. Most therapist work on a sliding scale anyways and she may be able to come to some affordable agreement with you. If she still insists that the insurance should cover it ask her if she is willing to call with you so that it can get resolved. Let her know how much this is bothering you (remember that she is a therapist). Maybe in the end it is an error on the insurance's part. If you'd rather not have this conversation face to face with the therapist, maybe you could call her and speak to her on the phone or leave a detailed message on her voicemail to allow her to process it. I hope it goes well and you can put this behind you.

I hope I haven't misunderstood the story, but I don't honestly see why you should be expected to pay anything but your contracted co-payments and/or deductibles. If your insurance company put the therapist's name on their list of providers in error, they, and not you, should be responsible for the resulting charges which you incurred in good faith. If the therapist's disappearance from the list was her fault in part, then she should share in the loss (as she should if her delay in billing was a contributory factor). You might consider a token payment, for the sake of goodwill, but a fairer and better thing to do would be to press your insurer to pay. It sounds to me as if your insurer has been barely ethical. Help level the field for honest insurers by not letting them get away with it.

That said, the paperwork you signed at the beginning of treatment very likely contains a clause in which you accepted responsibility for whatever the insurer doesn't pay. In that case, you could be forced to pay, and would have to press your insurer to reimburse you. Pretty fed up with insurance company antics!

I'll add my 2 cents even though there have been lots of good responses relating to how to manage the insurance/therapist issue. I am a health care provider, not a therapist, but when I work with a family I feel I have a responsibility to work WITH a family to help them and their child. It is a huge commitment to take a child to therapy, and it's hard enough to worry about whether your child is OK without being worried about bills, too. If I were the therapist I would meet the family 95% of the way, ask for whatever the usual copayment would be, and do my best to help the child complete therapy. I think that kind of goodwill always comes back to you in another form. If the money issue bothered me, I'd refer them to someone else, but gradually. I have been burned a few times, but it doesn't happen often. another opinion