| Below is information on how to obtain mental health services. The information describes how to obtain services if you have Medical Assistance, Medicare, private health insurance or are uninsured.
- Accessing Mental Health Treatment for Medical Assistance Recipients
- Accessing Mental Health Treatment for Medicare Recipients
- Accessing Mental Health Treatment for Individuals with Private Health Insurance
- Accessing Mental Health Treatment for the Uninsured
- Accessing Mental Health Treatment for Children
- Getting Help with Prescription Medications
Accessing Mental Health Treatment for Medical Assistance Recipients
All categories of Medical Assistance eligibility cover some level of mental health services. Below is information on accessing these services through HealthChoices (the managed care program) and through the Access Card (the Fee-For-Service system).
HealthChoices
If you are enrolled in HealthChoices, there are three ways that you can access mental health services.
- Contact your behavioral health Managed Care Organization's (MCO) member services line. Each MA recipient enrolled in HealthChoices has a behavioral health MCO available to provide them with any mental health or drug and alcohol services that they might need. If you are unsure of the name of your behavioral health MCO or how to contact them, call HealthChoices Enrollment Services at 800-440-3989 or TTY 1-800-618-4225. Once you are in touch with your behavioral health MCO, the member services staff will give you the names of at least two programs that can schedule you for an assessment. You will then need to call these programs directly to schedule your appointment.
- Contact your County Mental Health/Mental Retardation (MH/MR) Program. Each county has a MH/MR office. The County MH/MR staff will schedule you for an assessment to see what type of treatment you need. Click here to find contact information for your County MH/MR Program.
- Contact a mental health provider to see if he or she is able to see you. Only providers who are members of your behavioral health MCO will be covered by your HealthChoices coverage.
The levels of mental health treatment available through your MA-MCO are:
- Outpatient
- Partial Hospitalization
- Inpatient Hospital
- Crisis Intervention
- Intensive Case Management (ICM)
- Resource Coordinator (RC)
- Clozapine Services
Your MCO may offer additional services.
You may need other mental health services not provided by your MCO. These other services may be available from the County MH/MR Program.
Remember: Prescription drugs used to treat mental health conditions are obtained through your Physical Health Managed Care Organization. For more information on HealthChoices managed care, see our page on Managed Care.
See our Publications Page for more information on accessing Mental Health services through HealthChoices in your area.
If your Managed Care Organizations (MCO) denies treatment you need, reduces your services, or terminates services you are receiving you can appeal the decision directly to the Managed Care Organization, request a Fair Hearing from the Department of Public Welfare (DPW), or do both. For more information on appeal decisions about treatment, see our brochure on Complaints, Grievances, and Fair Hearings.
Fee-For-Service/Access Card
If you are enrolled in the Fee-For-Service system, you can access mental health services by calling the Mental Health/Mental Retardation (MH/MR) Program in your county. You will either be scheduled for an assessment at the county, or you will be given the names of at least two mental health providers to call directly for an assessment. Click here to find contact information for your County MH/MR Program.
The levels of mental health treatment available through Medical Assistance Fee-For-Service are:
- Outpatient Services
- Partial Hospitalization
- Inpatient Hospitalization
There are some limits on the type or amount of mental health services you may be able to receive. These limits depend on your category of Medical Assistance eligibility. Children are always entitled to any treatment that is medically necessary. Check the MA “Fee-For-Service Consumer Handbook” for more information about your coverage.
If Medical Assistance denies treatment you need, or reduces payments or stops paying for services you are receiving, you can appeal the action by requesting a Fair Hearing with DPW. You are entitled to a decision in writing if MA denies, reduces or stops services. That decision must tell you how to file an appeal. For more information on appealing decisions about treatment, see our page on Complaints, Grievances, and Fair Hearings.
See our Publications Page for more information on accessing mental health services through Access Card/Fee-For-Service in your area.
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Accessing Mental Health Treatment for Medicare Recipients
Recipients on Medicare can access some mental health treatments through Medicare. The Medicare program will cover a portion of the cost of certain services, if those services are reasonable and necessary according to Medicare's written standards. Part A covers a portion of the cost of a person's reasonable and necessary mental health treatment received in a hospital, including room, meals, nursing and other services. Part B covers a portion of the cost of the services of mental health professionals (whether inpatient or outpatient), outpatient therapies, lab tests and partial hospitalization assuming these are reasonable and necessary per the Medicare standards. Part B nevers covers more than 50% of outpatient mental health services.
To access mental health services through Medicare, you should ask your doctor or call 1-800-MEDICARE to check if Medicare is likely to cover the treatment or service you need. Medicare does not prior authorize treatment or services and will not tell you ahead of time whether a treatment or service will definitely be covered in your situation.
Medicare does not cover the total cost of most treatment and services, so recipients are normally required to pay deductibles and co-payments. If you have Medical Assistance as well as Medicare, your Medical Assistance can be used to cover co-pays and deductibles. If you have Medical Assistance and Medicare, your providers must accept that coverage as payment in full and cannot bill you for any balance on covered services. For more information about ‘payment in full' protections for persons who are dual eligible, see our Dual Eligibles page.
If Medicare denies you any service you have appeal rights. See your “Medicare & You 2007” handbook for details on appeals.
See our Publications Page for more information on accessing mental health services through Medicare.
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Accessing Mental Health Treatment for Individuals with Private Health Insurance
Whether or not your private health insurance covers mental health treatment depends on whether the plan is an ERISA or non-ERISA plan. The Employee Retirement and Income Security Act is a federal law that sets standards for certain health plans offered by employers. If your insurance is through an employer, call and ask your employer's benefits manager if you have an ERISA plan.
ERISA plans do not have to cover mental health treatment, but if your plan does, and if 50 or more employees are covered by the plan, any lifetime or annual caps on mental health services must be set as high as those for physical health services.
If you are in a Non-ERISA plan that covers 50 or more employees, it must cover nine “serious mental illnesses.” These are: schizophrenia, bipolar disorder, obsessive-compulsive disorder, major depressive disorder, panic disorder, anorexia nervosa, bulimia nervosa, schizoaffective disorder, and delusional disorder. Any annual or lifetime limits on coverage for these services must be no less than for other illnesses. Furthermore, coverage for these illnesses must include 30 days of inpatient and 60 days of outpatient care per year.
Read your member handbook or your insurance contract to see how to access services. Those materials will also contain information about appealing a denial of services.
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Accessing Mental Health Treatment for the Uninsured
If you have no health insurance, you may still be able to get mental health services. There are two options for those without insurance. The first option is to apply for Medical Assistance. The second option is to contact the Mental Health/Mental Retardation (MH/MR) Program in your county.
Qualifying for Medical Assistance
You may be able to qualify for health insurance, through Medical Assistance, because of your mental health problems. There are a number of programs available to individuals who have a mental health, or other, “disability.”
For more information on Medical Assistance eligibility, see our MA Eligibility Page.
County MH/MR Programs
If you do not have health insurance and are not eligible for Medical Assistance under the programs mentioned above, contact the Mental Health/Mental Retardation (MH/MR) Program in your county for information on ways to access services. Click here to find contact information for your County MH/MR Program.
When you call your County MH/MR Program you will be scheduled for an assessment to see what type of treatment you need. You will also be asked about your income to see if you can afford to pay for part of your treatment. The levels of mental health treatment available through the county are:
- Outpatient Services
- Partial Hospitalization
- Inpatient Hospitalization
- Intensive Case Management (ICM)
- Resource Coordinator (RC)
The County has different ways of paying for your treatment when you have no insurance. Whether or not you get the type of treatment you need depends on the money the County has available. However, some level of treatment should always be available to you.
Return to the top of this page. Accessing Mental Health Treatment for Children
In order to get mental health services for children, you should follow the same steps listed previously depending on the type of health insurance coverage your child has.
If your child has been seen by a doctor and has a severe mental health “disability,” he or she may qualify for Medical Assistance. For more information see the brochure Getting Medical Assistance for a Child with a Severe Disability, Mental Illness or Behavioral Disorder Under the “Loophole.”
Remember that children who receive Medical Assistance are entitled to any treatment that is medically necessary. Some of the additional treatment services that are available to children are:
- Residential Treatment Facility (RTF)
- Behavioral Health Rehabilitation Services (BHRS) – (“wraparound”).
- Family Based Mental Health Services
If your child is on CHIP, she will also receive some mental health services. The following types of mental health treatment are available through CHIP.
- Inpatient Hospitalization up to ninety (90) days per year (physical and mental health combined)
- Outpatient Mental Health Services up to fifty (50) visits per year (that can be exchanged for inpatient hospital days).
Read your CHIP Member Handbook or check with your plan directly to see what mental health services may be covered.
See our Publications Page for more information on accessing mental health services for children.
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Getting Help with Prescription Medications
If you are having trouble accessing mental health prescription medications there are programs that may be able to help.
If you are uninsured or your insurance does not include prescription drug coverage, it may be possible to get your mental health medications paid for by the County. Contact your County Mental Health/Mental Retardation (MH/MR) Program for more information. Click here to find contact information for your County MH/MR Program.
The Department of Public Welfare also runs a program called the Special Pharmaceutical Benefits Program. This program is for people with low or moderate income, who have a diagnosis of schizophrenia. It will pay for certain medications. To be eligible for this program, your gross income for a household of one must be $30,000 a year or less and you must have a prescription from your doctor for one of the medications the program covers. To qualify for this program you cannot be on Medical Assistance. Call 1-800-922-9384 for more information about this program.
For more information on accessing prescription drugs see our Accessing Prescription Drugs Page.
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