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Finding a Behavioral Health Provider through Your Private Insurance

Ann Geddes - Saturday, November 23, 2019

Have you had trouble finding an in-network behavioral health provider for your loved one through your private insurance?

Here at MCF we hear stories about tremendous barriers families face including:

  • Online provider directories that are inaccurate or out of date. They fail to note that a provider is not taking new patients, or is no longer taking a certain insurance plan, or has moved. This results in repeated phone attempts to identify a provider that can help.
  • Potential providers have lengthy waiting lists, which makes it difficult to find help, especially during a crisis.
  • Potential providers are located too far away from your home, which adds stress and time to your busy lives, especially when your family is struggling.

These problems can be especially true when looking for a child and adolescent therapist and psychiatrist.

You do have rights and there are many resources—you just need a bit of information and then understand how to apply it to your family. First of all, you should know that you are not alone if you are having difficulty finding providers. Because this impacts so many people, Maryland has put in place network adequacy requirements for private insurers. Please be aware that these requirements do not apply to certain plans, including federal and state employee plans. Check with your Human Resources Department for information about your plan.

Here are some of the specific requirements that can help your family.

  1. Insurers are required to offer you an appointment to a mental health or substance use provider within 10 days of the request. This includes psychiatrists.
  2. In urban areas the provider must be within 10 miles of the consumer, in suburban areas within 25 miles, and in rural areas within 60 miles.
  3. If private insurers cannot comply, they must allow a consumer to go out-of-network. If you are in an HMO, this must be at no additional cost to you. If you are not in an HMO, the insurer only needs to pay the out-of-network provider the amount that they would pay to an in-network provider. Then the provider can “balance bill” the patient who must pay the difference between what the provider charges and the amount that the insurance company reimburses the provider. This difference can be significant. As a solution, sometimes the insurer will enter into a “single case agreement” with a specific provider and negotiate a more reasonable rate (minus the patient’s co-payment). Ask your insurance company or provider if they are willing to help with this.

If your insurance company is in violation of any of these requirements, you should immediately report this to the Maryland Insurance Administration and the Health Education and Advocacy Unit of the Attorney General’s Office. Resources to file a complaint:

  • This short video, Your Rights When Your Insurer or HMO Says No, walks you through the process.
  • For specific information about how to file a complaint with the Maryland Insurance Administration, go here
  • For specific information about how to file a complaint with the Health Education and Advocacy Unit of the Attorney General’s Office, go here

Know your family’s rights, and advocate for them! Filing a complaint not only helps you, it alerts state agencies to existence of problems that are impacting others and the potential need for greater oversight.

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