|As of July 1, 2019
||Beginning July 1, 2020
Insurance plans are expected to develop networks of providers to deliver services. Based on a plan’s network, services should take place in the least restrictive, clinically appropriate setting. These settings might include a clinic, home, or a community setting.
Coverage for most Behavioral Health services for Children and Adolescents starts on your first annual plan renewal date that occurs on or after July 1, 2019. You can find out when your health plan renews by checking your health plan documents, calling your health insurance company, or asking your employer’s Human Resources Department.
If your plan is fully-insured (also sometimes called fully-funded) it is participating in covering Behavioral Health services for Children and Adolescents. Providing the benefit is a requirement for fully-insured plans. A fully-insured plan is a plan purchased by your employer from an insurance company. You and/or your employer pay the premiums and the insurance company pays the claims for covered services. A plan purchased by you through the Health Connector or directly from a Massachusetts health insurance company is also fully-insured/fully funded.
Self-insured or self-funded health plans are not participating plans. Self-funded health plans often look the same as a fully-insured plan, because employers usually hire an insurance company to manage or administer the self-funded health plans. Your health plan card/materials may have an insurance company name or logo on them, even if the plan is self-funded. Please do not assume that an insurance company name or logo on your card/materials means that your health plan provides the Behavioral Health services for Children and Adolescents.
If you are not certain which type of plan you have, ask your employer’s Human Resources Department or contact your plan directly to ask if these services are covered.
MassHealth is not subject to this requirement. MassHealth already covers very similar services through the Children’s Behavioral Health Initiative (CBHI): https://www.mass.gov/childrens-behavioral-health-initiative-cbhi
A child’s primary care provider, pediatrician, or a licensed mental health professional can refer a child for services. A child’s parent or legal guardian can directly contact behavioral health providers in their community to seek behavioral health services.
Yes. Each plan has set specific criteria to determine eligibility for each service. A behavioral health provider from your plan will work with you to understand if your child qualifies for and may benefit from these services.
Yes. Services are covered until the individual’s 19th birthday. Individuals 19 to 21 may be able to access similar services through MassHealth Secondary. To learn more about applying for MassHealth visit: https://www.mass.gov/how-to/apply-for-masshealth-the-health-safety-net-or-the-childrens-medical-security-plan
No. There is not a set number of days or visits that are covered.
No. Tuition-based programs that offer educational, vocational, recreational, or personal development activities, such as a therapeutic school, camp, or wilderness programs are not required to be covered. But the health plan must provide coverage for medically necessary covered services provided while the individual is in the program, if they would otherwise be covered, so long as the services are billed separately.
Yes. The advent of commercial coverage for these services has no bearing on eligibility for MassHealth supplemental coverage.
- Find out what type of insurance plan you have. Is it fully-funded/fully-insured? If so, this change applies to you.
- Talk with your health plan. Ask if they will continue to cover your child’s current provider(s) and services. If not, either request a list of providers that will be in your network or work with your health plan to find appropriate providers.
- Talk with your child’s current behavioral health provider(s). Share your insurance information and ask if there will be any impact to your child’s services and if your child will be able to continue with their current provider(s).
Contact one of the following support organizations for information and help:
- Parent/Professional Advocacy League: Visit ppal.net or call (866) 815-8122.
- Mass Family Voices/F2F Health Information Center at the Federation for Children with Special Needs: Visit https://fcsn.org/mfv/ or call (800) 331-0688.
- The Insurance Resource Center for Autism & Behavioral Health: Visit massairc.org or call (774) 455-4056.
You can contact the organizations above if you experience any problems. As these new services begin to be offered, it is especially important to report any issues or concerns you have in accessing care for your child to the Massachusetts Division of Insurance:
Massachusetts Division of Insurance:
Toll Free Number: (877) 563-4467
Main Phone Line: (617) 521-7794
Email Customer Service: firstname.lastname@example.org