Insurance for kids' mental health, in plain English

Insurance for kids' mental health is annoying. Here is the short version. What is covered. What costs money. What to call your plan about. Five minutes.

The fast version

• Therapy is usually covered. You pay a copay per visit.
• Medication is almost always covered. Generic versions are cheap.
• Doctor visits are covered like any other doctor visit.
• Long testing batteries are the wild card. Always call first.
• The law says mental health has to be covered like physical health.

The four pieces

Doctor visits. Pediatrician visits for mental health stuff are covered like any other doctor visit. Normal copay. The pediatrician can handle a lot of mental health care for kids. You do not always need a specialist.

Therapy. Sessions with a therapist, psychologist, or counselor. Covered. You pay a copay each time, usually $20 to $60 if the therapist is in-network.

Medication. Pills your kid takes. Covered. Generic versions are cheap (often $5 to $20 per month). Brand names cost more.

Long evaluations and testing. The 6 to 12 hour psychological testing battery. Covered sometimes, denied sometimes. Always call your plan before booking. Costs $1,500 to $4,500 if not covered.

The two laws that matter

The Affordable Care Act. Most plans have to cover mental health. You cannot be charged more or denied because your kid has a mental health condition.

The Mental Health Parity Act. Mental health benefits have to be the same as physical health benefits. Same copay levels. Same visit limits. Same rules. If your plan is breaking this rule, you can appeal and you will often win.

The five words to know

• In-network. The doctor has a deal with your insurance. You pay less.
• Out-of-network. No deal. You pay more.
• Copay. Flat fee per visit. Pay at the visit.
• Deductible. What you pay before insurance starts paying.
• Prior authorization. Pre-approval for some services. The doctor handles it.

Before you book, call your plan

A short list of questions. Write them down. Get the rep's name and a reference number for the call.

1. Is this provider in-network?
2. What is my copay or coinsurance for behavioral health?
3. Have I met my deductible?
4. Do I need prior authorization?
5. Are these CPT codes covered for this diagnosis?

The provider's office knows the codes. Ask them, then call your plan.

Why finding an in-network therapist is so hard

It is not in your head. About half of US child mental health clinicians do not take insurance directly because the rates are too low and the paperwork is too much.

Three things help:

• Call clinicians directly to confirm they take your specific plan. The website lists are usually wrong.
• Ask about telehealth. Often more in-network options online.
• If you cannot find an in-network provider with reasonable wait time, ask your insurance about a "single case agreement" to cover an out-of-network provider at in-network rates.

When the bill is higher than you expected

Three common reasons:

1. The provider was actually out-of-network. Always confirm directly with the office, not just the website.
2. You had not met your deductible yet. Each year resets.
3. The wrong code was billed. Sometimes a behavioral health visit gets billed under medical (or vice versa) and gets denied. The office can refile.

If the bill is wrong, call the office first to check the codes. Then call your insurance to appeal. Many bills get corrected.

If your plan won't cover what you need

Three options that work:

Appeal. Your doctor writes a letter explaining why this care is needed. The insurance company has to consider it. Many appeals succeed.

Sliding-scale care. Community mental health centers and many universities have therapy and psychiatry at reduced fees based on income. Quality is usually good, the trade-off is sometimes a waitlist.

HSA or FSA. If you have one of these accounts, mental health care counts as a qualified expense. Use those dollars for therapy, psychiatry, and even testing.

On Medicaid

For families on Medicaid, mental health for kids is usually well covered. Often no copays. The hard part is finding a clinician who takes Medicaid. Your state Medicaid office, your pediatrician, and the local community mental health center are the right places to start.

The takeaway

Most mental health care for kids is covered. The system is harder to use than it should be. The questions worth asking are short. The most useful single thing you can do is call your plan before you book any non-routine appointment, get answers in writing where you can, and appeal when something gets denied that should not have been.

Your kid's care is worth the phone call.