If you have not already received information about your health plan, ask your benefits manager for a copy of your health plan benefits; you have a right to have one of your own to keep. Does this document describe what mental health care and substance abuse treatment benefits you are entitled to? Does it explain how to get services and how to appeal coverage decisions you do not agree with? Does it explain what your financial responsibilities are? Is the coverage equal to that offered for other illnesses?
Individuals have the right to be provided information from the purchasing entity (such as the employer or union or public purchaser) and the insurance/third party payer describing the nature and extent of their mental health and substance abuse treatment benefits. This information should include details on procedures to obtain access to services, on utilization management procedures, and on appeal rights. The information should be presented clearly in writing with language that the individual can understand.
Ask your benefits manager which mental health professionals are covered by your plan. Does the plan cover a full range of mental health professionals? What is their training and experience? Are they licensed or certified? What kinds of treatments are avaiable? What treatments are excluded?
Individuals have the right to receive full information from the potential treating professional about that professional's knowledge, skills, preparation, experience, and credentials. Individuals have the right to be informed about the options available for treatment interventions and the effectiveness of the recommended treatment.
Individuals have the right to be informed by the treating professional of any arrangements, restrictions, and/or covenants established between the third party payer and the treating professional that could interfere with or influence treatment recommendations. Individuals have the right to be informed of the nature of information that may be disclosed for the purposes of paying benefits.
Appeals and Grievances
If you have concerns about the certification or authorization of treatment decisions made by the payer or insurance company, ask how you can appeal them to the payer, your employer or the purchasing agent, or to outside regulatory agencies. Ask what methods you can use to complain if you don't agree with the care provided by the professional. You have the right to complain to regulatory boards and/or professional associations which have grievance processes, and you have the right to air your complaints to your union, your state and federal legislators, and to the media.
Individuals have the right to receive information about the methods they can use to submit complaints or grievances regarding provision of care by the treating professional to that profession's regulatory board and to the professional association. Individuals have the right to be provided information about the procedures they can use to appeal benefit utilization decisions to the third party payer systems, to the employer or purchasing entity, and to external regulatory entities.
Find out if the information to be disclosed to the payer would be anything other than diagnosis, prognosis, type of treatment, time and length of treatment, and cost. Will the organizations receiving this information keep it as confidential as the mental health professional? How will they protect it? Are there penalties for disclosing information improperly?
If your information is transmitted, stored, or used for any purpose as data, will information that identifies you be removed to protect your privacy? Will the information be transferred to others or sold?
Individuals have the right to be guaranteed the protection of the confidentiality of their relationship with their mental health and substance abuse professional, except when laws or ethics dictate otherwise. Any disclosure to another party will be time limited and made with the full written, informed consent of the individuals.
Individuals shall not be required to disclose confidential, privileged, or other information other than diagnosis, prognosis, type of treatment, time and length of treatment, and cost.
Entities receiving information for the purposes of benefits determination, public agencies receiving information for health care planning, or any other organization with legitimate right to information will maintain clinical information in confidence with the same rigor and be subject to the same penalties for violation as is the direct provider of care.
Information technology will be used for transmission, storage, or data management only with methodologies that remove individual identifying information and assure the protection of the individual's privacy. Information should not be transferred, sold, or otherwise utilized.
Ask if you are able to choose any licensed/certified professional for your mental health care services. What professionals are covered and what are their credentials? What if you choose a licensed professional not usually covered by the plan?
Individuals have the right to choose any duly licensed/certified professional for mental health and substance abuse services. Individuals have the right to receive full information regarding the education and training of professionals, treatment options (including risks and benefits), and cost implications to make an informed choice regarding the selection of care deemed appropriate by individual and professional.
Determination of Treatment
Is anyone besides your professional involved in your treatment decisions? If so, do they have the same training and experience as your treating professional? Do they have a financial interest in the decisions they make?
Recommendations regarding mental health and substance abuse treatment shall be made only by a duly licensed/certified professional in conjunction with the individual and his or her family as appropriate. Treatment decisions should not be made by third party payers. The individual has the right to make final decisions regarding treatment.
Individuals have the right to receive benefits for mental health and substance abuse treatment on the same basis as they do for any other illnesses, with the same provisions, co-payments, lifetime benefits, and catastrophic coverage in both insurance and self-funded/self-insured health plans.
Individuals who use mental health and substance abuse benefits shall not be penalized when seeking other health insurance or disability, life, or any other insurance benefit. Quality mental health and substance abuse services should be provided to all individuals without regard to race, color, religion, national origin, gender, age, sexual orientation, or disability.
Benefit of Usage
The individual is entitled to the entire scope of the benefits within the benefit plan that will address his or her clinical needs.
Benefit of Design
Whenever both federal and state law and/or regulations are applicable, the professional and all payers shall use whichever affords the individual the greatest level of protection and access.
To assure that treatment review processes are fair and valid, individuals have the right to be guaranteed that any review of their mental health and substance abuse treatment shall involve a professional having the training, credentials, and licensure required to provide the treatment in the jurisdiction in which it will be provided. The reviewer should have no financial interest in the decision and is subject to the section on confidentiality.
Treating professionals may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence on the part of the professional. The treating professional has the obligation to advocate for and document necessity of care and to advise the individual of options if payment authorization is denied.
Payers and other third parties may be held accountable and liable to individuals for any injury caused by gross incompetence or negligence or by their clinically unjustified decisions.
Participating and Support Groups
American Association for Marriage and Family Therapy
American Counseling Association
American Family Therapy Academy
American Nurses Association
American Psychiatric Association
American Psychiatric Nurses Association
American Psychological Association
Clinical Social Work Federation
National Association of Social Workers
American Group Psychotherapy Association
American Psychoanalytic Association
National Association of Alcoholism and Drug Abuse Counselors
National Depressive and Manic Depressive Association
National Mental Health Association
Therapeutic Communities of America