Guide To Getting Insurance to Pay for Residential Treatment

Are you overwhelmed or frustrated by insurance policies that cover the cost of residential treatment? If so, here is a guide to getting insurance to pay for residential treatment.

This is a way to gain the quality care your child needs without worrying about potential denial, being unsure how to read insurance policies, or the stress involved in finding the right care for your child’s mental health and behavior needs. They take the fear out of the equation.

For more resources, check out mental health and insurance coverage or advocacy and support for mental health.

Understanding Residential Treatment & Insurance

What is Residential Treatment?

Residential treatment involves the individual living at a facility for an extended period of time. There are several different options; here are a few.

• RTC: A residential treatment center that offers a therapeutic and laid-out structure that will help create a routine of around-the-clock care and support for the individuals there.
• Wilderness Therapy: Outdoor activities are combined with other therapies to help the individual learn coping skills in a natural setting rather than sitting in a building.
• Intensive Outpatient Programs: In these programs, the individual participates in a program, goes home in the evenings, and does not have to stay in the facility. The treatment is intensive for the participant.
• Partial Hospitalization Programs: This is a step from having to stay in a facility. The individual goes a few times a week, or whatever their plan is, participates, and then gets to go home in the evenings.

Depending on the specific needs and severity of the conditions, it will depend on what options are available to your child.

Medical Necessity

This is a must when you are trying to get approved for care. This is needed to show that the child needs this particular plan that is being recommended or referred.

It can be a less intensive treatment, depending on what the specialists find best. If things need to be more intensive, then you have proof showing insurance that this is medically necessary.

Insurance Policies and Mental Health

Depending on where you live, policies and parity laws will vary, as will limitations that might arise.

Coverage will be available if deemed necessary, but it varies greatly.

The parity law requires insurance plans to provide the same coverage for substance abuse, disorders, and mental health issues as they would a medical health condition. So that is something to be aware of.

But even with the parity law, some insurance plans still have limits that require price caps, restrictions, out-of-network provider issues, and more. Ask your insurance provider about these.

The Process on Getting Insurance to Pay for Residential Treatment

Securing insurance coverage for residential treatment can be a complex process. This guide will walk you through the steps involved in obtaining the necessary insurance benefits to cover your treatment.

1. Gather Your Documentation

You must do your work and ensure you have your documentation to do all you can to get residential treatment with insurance coverage.

• Doctor’s Assessment Paperwork: Your primary care physician or even psychiatrist needs to create a paper that shows the diagnosis, treatment history, recommendations, and other information that showcases what your child might need for future treatments.
• School Reports: If your child has an IEP or any other behavioral issues documented at school, I suggest getting copies to show how their behavior impacts their learning.
• Therapy Notes and Recommendation: If your child is seeking therapy, ask for documentation of medications, challenges, treatment in past attempts, etc. They can also write a recommendation letter to justify this attempt at a treatment plan you are looking for.
• Behavior Logs: Behavior logs are an excellent resource for showing the struggles over months or years.
• Personal Notes: Feel free to have each parent write how their child impacts their life. If you have missed work, are struggling to meet daily needs, etc.

2. Contacting Your Insurance Company

• Pre-Authorization: Before starting treatment, you must get your insurance company to pre-authorize the treatment plan to ensure it is covered under your plan.
• Be Prepared: You will want to ask about in-network providers, whether you have out-of-network provider clauses, what your deductible is, and if you have a specific location where you are looking for treatment. Make sure to know your cost, what they cover, etc. You can ask the treatment location to help with common questions to ask about your insurance.
• Get It in Writing: When you do all this, ask them to email or mail letters or information showing the communication; take notes yourself. Also, write down who you talked with on the phone, including reference numbers. This will come in handy later if they change what you were told.
• Persistence Pays Off: Prepare for potential initial denials. That can happen; the biggest thing is to stay persistent and try again. You can sometimes get denied a few times before your treatment plan is accepted.

4. The Appeals Process

Here are some steps to take if the claim you submitted gets denied. You do have the right to appeal.

• Your Right to Appeal: You should contact insurance and ask for a formal denial letter. They are required to provide it. You can have them mail it to your home or email it.
• Gathering Support: After reviewing the appeal, try to gain more support or information to back up your claim with more letters of recommendation, detailed documents or logs, etc.
• Independent Review: If you find your appeals are not getting approved, you can contact a third party to help with the review.
• Legal Assistance: You can reach out to an attorney for guidance or steps that might need to be taken to explore any legal options.

5. Additional Strategies for Maximizing Insurance Coverage

• State Parity Laws: Make sure to look up your specific state’s Parity laws and see how you can maximize their use, as well as other protections that might be available in your area.
• Employer-Based Plans: Contact your HR department and see if they can offer more benefit options, resources, etc., for your insurance plan. They can sometimes help you find ways to get the proper information.
• Non-Profits and Advocacy: Check out your area or online where non-profit organizations and advocacy groups can offer help and insight on steps to navigate your insurance company correctly.

Getting your insurance to approve the claims you submit to ensure you are covered can sometimes be tricky. But this guide can help you get a yes much quicker and speed up the process.

While it might seem challenging, remember that you are doing this to help your child get the necessary care. Use the resources to get one step closer to getting things approved and treatment started. Be the advocate for your child or loved one in your life.

More Helpful Resources About Residential Treatment

Download Residential Treatment Report {Exclusive Access to 75+ Parent Reviews & Practical Advice}

Sample Letter of Medical Necessity for Residential Treatment

7 Steps to Take When Your Child Needs Residential Treatment

Child & Teen Behavior Log For Treatment Decisions (FREE PDF)

How to Get Funding Available for Residential Treatment for Children