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Getting Mental Health Coverage for Out of Network Providers

Finding the appropriate mental or behavioral health clinician in a managed care network may be very hard. There are laws in Massachusetts that are intended to make finding appropriate services easier. However, most people do not know about the laws or how to use them to get coverage for services.

OPTION 1: Request Out of Network Authorization from your Network

If your network does not have a provider trained and experienced in handling your clinical needs in your area, be aware that the Managed Care Reform Act requires most Massachusetts managed care and insurance companies to provide adequate access. This includes access to "all mandated provider types” (e.g., psychologists); a full range of mandated services including specific treatment modalities appropriate for all ages of patients and for all types of covered mental conditions. There must be a sufficient number of providers available in the network so that no patient need wait a medically inappropriate length of time to receive care for medically necessary conditions. If you believe your network is not complying with the law you may insist that they provide a single case agreement for the doctor you believe can meet your needs.

Typically you must be prepared to demonstrate that you have tried and failed to find a psychologist within your area, who has the expertise and training you need, and is available in your network, before they will give an out-of-network authorization.

If they refuse you may want to inform them that you believe they may be breaching their contract with you.

You may wish to request to speak to a supervisor. Let them know you if you plan to file a complaint with the Bureau of Managed Care and your employer’s human resources department.

OPTION 2: Contact the Bureau of Managed Care

If they refuse to provide an out –of- network authorization you may file a complaint with the Bureau of Managed Care at 617-521-7372, by fax at 617-521-7773, or by email at bmc.mailbox@state.ma.us. More information about the law is also available at their website http://www.state.ma.us/doi/Managed_care/Managed_care_on.html.

OPTION 3: Contact the Human Resources Department at your Employer who is providing the health coverage

Inform them that you are unable to find appropriate care within the network and are unable to obtain an out- of -network authorization and request their help. The employer is the "customer” who the insurers want to please. When employers contact the sales department at managed care companies they are usually successful at obtaining authorization.

OPTION 4: Request Help from Mental Health Legal Advisors

Contact Susan Fendell at the state’s Mental Health Legal Advisors. You may contact her by email at sfendell@email.mhl.state.ma.us. She has been very successful in convincing local HMOs to provide coverage for out of network doctors when they are not available in the network. You can call her at 617-338-2345.

OPTION 5: Let the Lawmakers Know That the Law is Not Being Followed and Request Action

Commissioner of Public Health, Christine C. Ferguson
250 Washington Street
Boston, MA 02108-4619

Director, Office of Patient Protection via Facsimile 617-624-5046

Julie M. Bowler, Commissioner of the Massachusetts Division of Insurance,
via Facsimile 617-973-8798

Senator Richard Moore
Chairperson of the Joint Health Care Committee
RMoore@senate.state.ma.us

Senator Guy Glodis
Chairperson of the Insurance Committee
State House
Room 413B
Boston, MA 02133
GGlodis@senate.state.ma.us

Contact your State Senator and Representative
http://www.state.ma.us/legis/citytown.htm

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