Anthem
This guide will help you understand how Anthem BlueCross BlueShield covers mental health and substance use disorder treatment, so you can focus on healing.
When facing mental health challenges or substance use disorders, knowing your insurance coverage is crucial for accessing timely and appropriate care. Anthem BlueCross BlueShield (BCBS) provides comprehensive mental health coverage as part of their commitment to whole-person care, recognizing the important connection between mental and physical health.
Under the Affordable Care Act (ACA), all health insurance marketplace plans, including those offered by Anthem, must cover mental and behavioral health services as essential health benefits. This means that mental health and substance use disorder treatments are covered similarly to physical health services, with comparable deductibles, copayments, coinsurance, and treatment limitations—a concept known as mental health parity.
Anthem's approach to mental health care emphasizes integrated treatment that addresses both physical and mental aspects of health. Their behavioral health programs are designed to offer comprehensive support to members dealing with a range of mental health conditions and substance use disorders, connecting them with appropriate care providers and treatment options.
Types of Anthem Plans and Mental Health Coverage
Anthem offers several types of health insurance plans, each with different approaches to mental health coverage:
HMO (Health Maintenance Organization) plans typically require you to choose a primary care physician who coordinates your care and provides referrals to specialists. For mental health services, you generally need to see providers within Anthem's behavioral health network to receive in-network coverage.
PPO (Preferred Provider Organization) plans offer more flexibility, allowing you to see both in-network and out-of-network providers, though costs are usually lower when staying in-network. These plans typically don't require referrals to see specialists, including mental health providers.
POS (Point of Service) plans combine elements of both HMO and PPO plans. They provide in-network coverage when you see providers in the behavioral health network but also offer some out-of-network coverage, usually at higher cost-sharing levels.
Understanding your specific plan type is essential as it determines which providers you can see and how much you'll pay out-of-pocket for services.
Mental Health Services Covered by Anthem
Anthem BCBS 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
Anthem typically covers various outpatient mental health services, including individual therapy with licensed providers, psychiatric evaluations and medication management, group therapy sessions, and psychological testing. Many plans also cover intensive outpatient programs (IOPs) that provide structured treatment several days per week while allowing patients to maintain their daily routines.
Inpatient Services
For more acute mental health needs, Anthem 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, supervised treatment in a controlled environment.
Additional Support Services
Anthem also typically covers telehealth mental health appointments, allowing members to connect with providers remotely. Many plans include coverage for addiction recovery programs, crisis intervention services, and case management. Anthem's behavioral health care coordinators can help connect members with appropriate providers and coordinate different aspects of care.
Common Mental Health Conditions Covered
Anthem BCBS plans generally cover treatment for a wide range of mental health conditions and substance use disorders, including but not limited to:
Schizophrenia and other psychotic disorders
Substance use disorders
Autism spectrum disorders
Coverage for specific conditions may depend on the particular treatment being sought and medical necessity determination. Most conditions listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are eligible for coverage under Anthem plans.
Verifying Your Anthem 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. Here are steps to verify your benefits:
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 Anthem 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 Anthem's online provider directory 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 Anthem begins covering services).
For personalized benefit information, contact Anthem 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 Anthem 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
Anthem BCBS 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 Anthem'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 Anthem to justify the medical necessity of requested services.
Out-of-network providers may require you to secure authorization yourself by contacting Anthem's Prior Authorization department. You should verify this responsibility before beginning treatment.
Anthem uses the Interactive Care Reviewer (ICR) tool via Availity as its preferred method for providers to submit prior authorization requests for both inpatient and outpatient behavioral health services. This system allows providers to submit detailed information and track the status of authorization requests.
Failure to obtain required authorizations can result in denied claims, so it's essential to verify requirements before beginning treatment. For ongoing care, Anthem 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 Anthem's approval process can help ensure a smoother treatment journey:
Steps in the Approval Process
Initial assessment: A qualified provider evaluates your condition and recommends appropriate treatment.
Provider submission: For services requiring authorization, your provider submits clinical information to Anthem justifying the medical necessity of requested services.
Review and determination: Anthem reviews the information and makes a coverage decision based on medical necessity criteria.
Ongoing review: For continuing services like inpatient care, Anthem conducts concurrent reviews to assess continued need for the level of care.
Working with providers experienced with Anthem 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 Anthem.
Finding Anthem In-Network Mental Health Providers
Staying in-network typically results in lower out-of-pocket costs and smoother insurance processing. Anthem offers several ways to find in-network mental health providers:
Looking for a therapist or psychiatrist can begin with Anthem's online provider directory, accessible through their website or the Sydney Health app. Filter your search specifically for behavioral health providers in your area who accept your plan.
Anthem's behavioral health support line at 800-245-7013 connects members with specialty-trained clinicians who can help locate appropriate providers based on your specific needs and location. This service is available 24/7.
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 Anthem has negotiated lower rates with these providers. Consider telehealth options, as virtual visits may have lower copays than in-person appointments. Some providers offer sliding scale fees based on income, which can help make care more affordable.
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.
Unique Features of Anthem Mental Health Coverage
Anthem's Behavioral Health Resources
Anthem offers unique digital tools to support mental health, including online resources that provide guided meditation and stress management tools. Members can access articles, podcasts, and videos on various mental health topics through Anthem's digital platforms, offering education and self-help resources to complement professional treatment.
Integration with Primary Care
A distinctive aspect of Anthem's approach to mental health is their emphasis on integration with primary care. Anthem's behavioral health care coordinators work to ensure coordination between mental health providers and other healthcare professionals, creating a more holistic approach to treatment. This integration helps address the connection between physical and mental health conditions, potentially improving overall treatment outcomes.
How to Determine if Your Specific Anthem Plan Covers Needed Treatment
Mental health coverage can vary significantly between different Anthem plans. To determine if your specific plan covers your needed treatment, locate your Summary of Benefits document through your online Anthem 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 Anthem ID card. Mental health professionals familiar with Anthem 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 Anthem
Selecting a treatment facility that accepts Anthem 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.
Anthem's behavioral health care coordinators 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 Anthem's authorization requirements and typically handle most of this process for you.
Additionally, facilities in Anthem's network must meet certain standards for quality and appropriate care, providing some assurance about the quality of services.
Taking the Next Step in Your Mental Health Journey
Reaching out for help is a courageous first step on the path to better mental health. With Anthem coverage, you have access to a wide range of treatment options and supportive resources.
If you're not sure where to begin, Anthem's dedicated mental health support resources are available to help connect you with appropriate care options based on your specific needs and insurance coverage.
Remember that dealing with mental health challenges or substance use disorders is not something you need to face alone. With proper treatment and support, recovery and improved wellbeing are possible.
Find Treatment Centers That Accept Anthem Today
Ready to take the next step? Browse our directory of treatment facilities that accept Anthem 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.anthem.com/mental-health/connecting-to-mental-healthcare
[2] https://providers.anthem.com/california-provider/claims/prior-authorization-requirements