Health Insurance Coverage for Mental Health Services

Parent Q&A

  • 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.

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