AmeriHealth

When facing mental health challenges or substance use disorders, understanding your insurance coverage is vital for accessing appropriate care without undue financial strain. AmeriHealth provides comprehensive behavioral health coverage as part of their commitment to supporting the whole-person health of their members.

Under federal mental health parity laws, AmeriHealth is required to provide coverage for mental health and substance use disorder treatments as favorably as they provide coverage for other medical health services. This means that coverage for mental health services cannot be more restrictive than coverage for medical and surgical benefits. For example, if AmeriHealth provides unlimited coverage for physician visits for physical health conditions like diabetes, they must do the same for mental health conditions like depression or schizophrenia.

This parity requirement extends to various aspects of coverage, including treatment limitations, cost-sharing requirements, and authorization processes. AmeriHealth must maintain similar prior authorization requirements and coverage limitations for mental health and substance use disorder benefits as they do for other medical benefits.

Types of AmeriHealth Plans and Mental Health Coverage

AmeriHealth offers several types of health insurance plans, each with different approaches to mental health coverage:

• HMO (Health Maintenance Organization) plans typically require you to stay within AmeriHealth's network of providers for covered services. These plans generally don't cover out-of-network care except in emergencies, but they often have lower premiums than other plan types.

• PPO (Preferred Provider Organization) plans offer more flexibility, allowing you to see both in-network and out-of-network providers, though your costs are typically lower when staying in-network. These plans don't require specialist referrals from a primary care physician.

• EPO (Exclusive Provider Organization) plans don't require referrals to see specialists, but like HMOs, they only cover services from in-network providers. Their premiums are usually somewhere between those of HMOs and PPOs.

• Direct Point-of-Service plans combine elements of HMOs and PPOs, allowing you to use any doctor or hospital, but you'll pay less when choosing providers within the network.

Your specific plan type significantly impacts which mental health providers you can see and how much you'll pay out-of-pocket for services, so it's essential to understand your plan's structure before seeking care.

Mental Health Services Covered by AmeriHealth

AmeriHealth generally covers a wide range of mental health and substance use disorder services. While specific coverage details may vary by plan, commonly covered services include:

Outpatient Services

AmeriHealth typically covers outpatient mental health services including individual therapy with licensed providers, psychiatric evaluations and medication management, group therapy sessions, psychological testing, and substance use screenings. Many plans also include coverage for intensive outpatient programs (IOPs) that provide structured treatment several days per week.

Inpatient Services

For more intensive mental health needs, AmeriHealth generally covers inpatient services such as hospitalization for mental health crises, residential treatment programs, partial hospitalization programs (PHPs), and detoxification and rehabilitation services for substance use disorders. These higher levels of care provide structured treatment in controlled environments for acute conditions.

Additional Support Services

AmeriHealth also typically covers services like telehealth mental health appointments, crisis intervention and stabilization services, community-based supports, and case management services. Many AmeriHealth plans offer access to a behavioral health care navigation team that helps connect members with appropriate care based on their specific needs.

Common Mental Health Conditions Covered

AmeriHealth plans generally cover treatment for a wide range of mental health conditions and substance use disorders, including but not limited to depression and mood disorders, anxiety disorders, post-traumatic stress disorder (PTSD), bipolar disorder, schizophrenia and other psychotic disorders, eating disorders, substance use disorders, attention-deficit/hyperactivity disorder (ADHD), and autism spectrum disorders.

Coverage for specific conditions depends on medical necessity determination, and most conditions listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are eligible for coverage under AmeriHealth plans.

Verifying Your AmeriHealth Mental Health Benefits

Before seeking treatment, it's important to understand your specific coverage details to avoid unexpected costs and ensure you can access the care you need.

Start by reviewing your Summary of Benefits document, which outlines your mental health coverage, including copayments, coinsurance, deductibles, and any coverage limitations. This document can usually be accessed through your online AmeriHealth account or by contacting your HR department if you have employer-provided insurance.

Next, check provider network status by verifying if your preferred mental health provider is in-network using AmeriHealth's online "Find a Doctor" tool or by calling the provider directly with your insurance information. Remember that staying in-network typically results in lower out-of-pocket costs.

Understanding your financial responsibility is crucial, as mental health services usually require cost-sharing in the form of copayments, coinsurance (percentage of costs you pay after meeting your deductible), and deductibles (amount you pay before AmeriHealth begins covering services).

For personalized benefit information, contact AmeriHealth Member Services by calling the number on the back of your ID card. They can provide specific details about your coverage and answer any questions you may have.

Authorization Requirements for Mental Health Treatment

Many mental health services under AmeriHealth plans require prior authorization, especially for higher levels of care. Understanding these requirements can help avoid coverage denials and unnecessary expenses.

Services That Typically Require Prior Authorization

AmeriHealth typically requires prior authorization for inpatient hospitalization (except in emergencies), residential treatment programs, partial hospitalization programs (PHPs), and intensive outpatient programs (IOPs). Additionally, certain specialized treatments or extended therapy beyond plan-allowed sessions may also need authorization before services begin.

For emergency mental health admissions, providers must typically notify AmeriHealth's case management department within a specified timeframe. For non-emergency services requiring authorization, the request should generally be submitted before service delivery.

Authorization Process

The authorization process differs depending on whether you're seeing in-network or out-of-network providers:

• In-network providers typically handle the authorization process for you, submitting required clinical information to AmeriHealth to justify the medical necessity of requested services.

• For out-of-network providers (if your plan includes out-of-network coverage), you may need to secure authorization yourself by contacting AmeriHealth's Prior Authorization department. You should verify this responsibility before beginning treatment.

Failure to obtain required authorizations can result in denied claims, so it's essential to verify requirements before beginning treatment. For ongoing care, AmeriHealth may conduct concurrent reviews to determine if continued treatment at the current level of care is medically necessary.

Navigating the Insurance Approval Process

Understanding how to navigate AmeriHealth's approval process can help ensure a smoother treatment journey:

Steps in the Approval Process

1. Initial assessment: A qualified provider evaluates your condition and recommends appropriate treatment.

2. Provider submission: For services requiring authorization, your provider submits clinical information to AmeriHealth justifying the medical necessity of requested services.

3. Review and determination: AmeriHealth reviews the information and makes a coverage decision based on medical necessity criteria.

4. Ongoing review: For continuing services like inpatient care, AmeriHealth conducts concurrent reviews to assess continued need for the level of care.

Working with providers experienced with AmeriHealth authorization processes can help ensure all required documentation clearly demonstrates medical necessity. Following up on pending authorizations can prevent delays in care, and keeping records of all communication regarding authorizations is advisable.

If you receive a denial, you have the right to appeal. Your provider can help submit additional information to support your case, or you can file an appeal directly with AmeriHealth.

Finding AmeriHealth In-Network Mental Health Providers

Staying in-network typically results in lower out-of-pocket costs and smoother insurance processing. AmeriHealth offers several ways to find in-network mental health providers:

• AmeriHealth's online provider directory allows you to search specifically for behavioral health providers in your area who accept your plan. This tool makes it easy to find in-network doctors, therapists, and other mental health professionals.

• For personalized assistance, you can call the Member Services number on your AmeriHealth ID card. For behavioral health needs specifically, you may be connected with AmeriHealth's Behavioral Health Care Navigation team, which can assess your needs and help connect you with appropriate providers.

• Your primary care doctor can also be a good resource for referrals to in-network mental health providers. They may have recommendations based on your specific condition and treatment needs.

When searching for providers, consider factors beyond network status, such as experience with your specific condition, availability of appointment times, treatment approaches and specialties, location and accessibility, and telehealth options if needed.

Managing Out-of-Pocket Costs for Mental Health Care

Even with insurance coverage, you may have financial responsibility for some mental health treatment costs. Understanding and planning for these expenses can help make treatment more accessible.

Staying in-network is one of the most effective ways to manage costs, as AmeriHealth has negotiated lower rates with these providers. Consider telehealth options, as virtual visits may have lower copays than in-person appointments and offer greater convenience.

Check if your plan covers preventive mental health screenings without cost-sharing, and always review your out-of-pocket maximum, which caps your annual spending on covered services. This can provide protection against very high treatment costs.

Some AmeriHealth plans offer additional resources like MyStrength Plus, an online self-guided resource offering personalized programs and support for various mental health concerns, which may complement formal treatment.

Unique Features of AmeriHealth Mental Health Coverage

AmeriHealth's Behavioral Health Care Navigation

A distinctive aspect of AmeriHealth's approach to mental health is their Behavioral Health Care Navigation service. This team of trained professionals helps members quickly connect with quality care that meets their specific needs. The team can assess and understand members' needs, provide information about treatment options, identify in-network providers, and connect members directly to care. This personalized approach helps ensure members receive appropriate treatment and supports the coordination of physical and behavioral health needs.

Mental Health Parity Commitment

AmeriHealth places a strong emphasis on mental health parity, ensuring that mental health and substance use disorder treatments are covered as favorably as medical treatments. This commitment means AmeriHealth maintains similar requirements for things like prior authorization, treatment limitations, and cost-sharing across both physical and mental health services. Members who believe their plan isn't providing parity between mental health and medical services have the right to file an appeal or grievance. This dedication to parity helps reduce barriers to accessing mental health care.

How to Determine if Your Specific AmeriHealth Plan Covers Needed Treatment

Mental health coverage can vary significantly between different AmeriHealth plans. To determine if your specific plan covers your needed treatment, locate your Summary of Benefits document through your online AmeriHealth account or contact your employer's HR department. This document outlines your specific coverage details for mental health and substance use disorder benefits.

Look for service-specific information about different levels of care (outpatient, inpatient, etc.) and any limitations on number of visits or days of coverage. Verify in-network vs. out-of-network coverage differences and understand any authorization requirements for specific services.

For questions about specific treatments or providers, call the Member Services number on your AmeriHealth ID card. Mental health professionals familiar with AmeriHealth can often help interpret coverage for specific treatments.

Remember that coverage determination ultimately happens when claims are processed, based on your eligibility, plan terms, and the specific services provided.

Benefits of Choosing a Facility That Accepts AmeriHealth

Selecting a treatment facility that accepts AmeriHealth insurance offers several advantages, including lower out-of-pocket costs due to negotiated rates and a streamlined billing process where the facility handles insurance paperwork directly.

AmeriHealth's behavioral health care navigation team can often work more effectively with in-network facilities to ensure appropriate care and smooth transitions between treatment levels. In-network facilities are familiar with AmeriHealth's authorization requirements and typically handle most of this process for you.

Additionally, facilities in AmeriHealth's network must meet certain standards for quality and appropriate care, providing some assurance about the quality of services.

Find Treatment Centers That Accept AmeriHealth Today

Ready to take the next step? Browse our directory of treatment facilities that accept AmeriHealth insurance to find the right match for your needs. Our comprehensive listings include information about services offered, treatment approaches, and location details to help you make an informed decision.

Don't let insurance concerns delay your path to wellness. With the right coverage information and support, you can access the care you need to begin your recovery journey.

References

[1] https://www.amerihealthcaritasnh.com/member/eng/benefits/behavioral.aspx

[2] https://news.amerihealth.com/explainer-about-in-network-and-out-of-network-providers/

[3] https://www.amerihealth.com/get-care/behavioral-health/addiction-support-and-resources.html

[4] https://www.amerihealthcaritasnc.com/provider/resources/physical-prior-auth.aspx