Mental Health Care

Introduction

In general, mental health care provides support and treatment to optimize a person’s emotional and psychological well-being. Both state and federal laws require your health plan to provide treatment for mental health conditions. The California Mental Health Parity law specifies several mental health conditions that must be covered and the kind of treatment that will be provided for those conditions. This state law also requires plans to provide mental health treatment under the same terms and conditions that are applied when treating medical conditions. The federal Affordable Care Act adds many other mental health and substance use disorder conditions and treatments that plans must cover if you are enrolled in individual or small group coverage. For more information on the coverage mandated by the California Mental Health Parity law and the Affordable Care Act, please see Know Your Rights, below.

A federal law, the Mental Health Parity and Addiction Equity Act (MHPAEA), protects coverage for people with mental health or substance use disorders differently than the California Mental Health Parity law. MHPAEA prevents health plans that provide mental health or substance use disorder benefits from placing limits on those benefits that are less favorable than the limits placed on medical/surgical benefits. More specifically, health plans must ensure that financial requirements, such as copayments, coinsurance, and deductibles, and treatment limitations, such as the number and frequency of visits, which are applied to mental health or substance use disorder benefits are not more restrictive than the predominant requirements applied to most of the medical and surgical benefits. For more information on parity under MHPAEA, please see The Mental Health Parity and Addiction Equity Act.

If you feel you may have a mental health or substance use condition, your first step to get appropriate care is to contact your health plan or review your Evidence of Coverage (a booklet about your benefits) to see whether your plan covers mental health or substance use disorder benefits and which services it covers. If your health plan provides mental health or substance use disorder benefits, you can request an evaluation from a mental health care provider. Contact your medical doctor or your health plan for a list of mental health or substance use disorder providers.

Know Your Rights

Under the California Mental Health Parity Law, all health plans you buy yourself or get through your job must cover certain mental health conditions under the same terms and conditions applied to medical conditions.

The mental health conditions that must be covered include serious emotional disturbances of a child and the following nine severe mental illnesses:

  • Major depressive disorders
  • Bipolar (manic-depressive) disorder
  • Panic disorder
  • Anorexia nervosa
  • Bulimia nervosa
  • Obsessive-compulsive disorder
  • Autism or Pervasive Developmental Disorder
  • Schizophrenia
  • Schizoaffective disorder

Serious emotional disturbances (SED) is a term that refers to children under the age of 18 who have a diagnosable mental health problem that severely disrupts their ability to function socially, academically, and emotionally. This could include hyperactivity, a short attention span and impulsiveness, aggression, or self-injurious behavior such as acting out or fighting, withdrawal, a failure to initiate interaction with others or avoid social interactions through fear or anxiety, immaturity characterized by inappropriate crying and temper tantrums, and poor coping skills and learning difficulties including academic performance below grade level. Many children who do not have SED may display some of these behaviors. However, when these behaviors continue over long periods of time, those children may have serious emotional disturbances.

If you have one of the severe mental illnesses or your child has serious emotional disturbances, your plan must cover outpatient diagnosis and treatment, inpatient hospital services, partial hospitalization, and prescription drugs, if your health plan covers prescription drugs. California law also requires that all health plans cover behavioral health treatment for children, teens, and adults who have autism. 

The federal Affordable Care Act requires additional health plan coverage of more mental health conditions and substance use disorders, but only for health plans purchased by individuals or small group employers with 100 or fewer employees.

The Affordable Care Act’s additional mental health coverage in California requires treatment of almost all mental disorders, not just the nine severe mental illnesses or serious emotional disturbances of a child. The types of mental health treatment that must be covered include:

  • Outpatient individual and group mental health evaluation and treatment, psychological testing, and outpatient services to monitor drug therapy
  • Outpatient intensive psychiatric treatment programs, including hospital-based intensive outpatient care (partial hospitalization), and multidisciplinary treatment in an intensive outpatient psychiatric treatment program
  • Inpatient psychiatric hospitalization
  • Psychiatric observation for an acute psychiatric crisis
  • Treatment in a crisis residential program in a licensed psychiatric treatment program facility

The Affordable Care Act’s additional substance use disorder coverage in California requires treatment for alcohol and chemical dependency. This coverage must include:

  • Inpatient detoxification, which is hospitalization for medical management of withdrawal symptoms and includes dependency recovery services, education, and counseling
  • Outpatient evaluation and treatment for chemical dependency, including day-treatment programs, intensive outpatient programs, individual and group chemical dependency counseling, and medical treatment for withdrawal symptoms
  • Transitional residential recovery services, which include chemical dependency treatment in a nonmedical transitional residential recovery setting that provides counseling and support services in a structured environment

The following link will connect you to more information on your health care rights.

How to Get Care

You can ask for a referral from your primary care doctor, your mental health care provider, or your health plan. In some health plans, you may be able to make an appointment directly with a mental health care provider.

Read your Evidence of Coverage or call the phone number on your Membership Card to find out what you need to do to see a mental health provider. Some plans have a behavioral health care phone number on the membership card. You can call this number.

Health Plan Web Site List for Information About Getting Mental Health Services

You can check your health plan’s website for information about mental health services. Find the Web address of a specific Health Plan.

Types of Mental Health Providers

There are many types of qualified mental health professionals available to diagnose and treat minor to severe mental health disorders. The providers listed below are those trained in different areas of mental health care:

  • Psychiatrist - A licensed medical doctor who specializes in the diagnosis, treatment, and prevention of mental illnesses. They may work with you on everyday problems like stress or more complex issues like schizophrenia. Psychiatrists can prescribe medications.
  • Psychologist - A licensed specialist who provides clinical therapy or counseling for a variety of mental health care conditions. They have earned a doctorate degree in psychology and are required to complete several years of supervised practice before becoming licensed.
  • Counselor/Therapist - A specialist who provides mental health services to diagnose and treat mental and emotional health issues. They may use a variety of therapeutic techniques. Licensed Counselors have a master’s or a doctoral degree in counseling or a related area.
  • Neuropsychologist - A licensed psychologist with expertise in how behavior and motor skills are related to brain structures and systems.
  • Social Worker - A specialist who provides treatment for social and health problems. Some social workers may work in employee assistance programs or as case managers who coordinate psychiatric, medical and other services on your behalf. Others specialize in domestic violence or chronic illness. Most social workers have a master’s degree in social work; many are licensed as a LCSW.
  • Psychiatric Nurse - Licensed registered nurses (R.N.) who have extra training in mental health. Under supervision of medical doctors, they may offer mental health assessments and psychotherapy and they may help manage medications. Advanced practice registered nurses (A.P.R.N.) can diagnose and treat mental illnesses.
  • Marriage and Family Therapist (MFT) - Therapists who evaluate and treat disorders within the context of the family. These therapists provide help with a range of problems, such as depression, parent-child conflicts, and eating disorders.

Ask your doctor or health plan for a provider who is qualified and experienced to treat your condition. Some providers may treat only adults. Some providers may treat children and adolescents or certain kinds of mental health conditions. Some providers may treat patients with severe mental illnesses such as schizophrenia and eating disorders and others may only treat patients with less severe conditions.

Mental Health Care for Children

Children may experience a number of disorders, ranging from Attention-Deficit/Hyperactivity Disorder (ADHD) to depression. If not treated properly, these conditions can continue into adulthood.

If you have concerns regarding your child’s mental health, it is best to speak to your child’s primary care doctor first. They may refer you to a specialist, such as a developmental-behavioral pediatrician, psychologist, psychiatrist, pediatric neurologist, or speech therapist or occupational therapist. However, it's important to have a medical evaluation first to rule out other causes of your child's signs and symptoms.

Mental Health and Substance Use Disorder Care for Medi-Cal Members

The information above describes the mental health and substance use disorder conditions and treatments that must be provided to people who bought their coverage themselves or get it through their job. Most of these mental health and substance use disorder benefits are also available for people in Medi-Cal. Services covered by Medi-Cal include outpatient mental health services such as individual or group counseling, outpatient specialty mental health services, inpatient mental health services, outpatient substance use disorder services, residential treatment services, and voluntary inpatient detoxification. To find out how you or your child can get mental health or substance use disorder treatment through Medi-Cal, contact your Medi-Cal managed care plan or call the Medi-Cal Mental Health Care Ombudsman at 1-800-896-4042 and ask for an assessment or needed services.

Regional Centers

Another option for some people with developmental disabilities is to receive mental health care through a regional center. A regional center is a nonprofit, private corporation that contracts with the California Department of Developmental Services to provide or coordinate services. California has 21 regional centers with more than 40 offices located throughout the state.

To be eligible for regional center services, you must have a substantial disability that began before your 18th birthday and is expected to continue indefinitely. Infants and toddlers up to age 36 months who are at risk of having developmental disabilities or who have a developmental delay may also be eligible for regional center services. Persons interested in regional center services must first obtain a diagnosis and assessment of their disability from a regional center.

For more information on regional center services, supports, and eligibility, go to http://www.dds.ca.gov/RC/index.cfm.

Questions and Answers

What if my problem is not on the list of California mental health parity conditions?
You may still be able to get care from your health plan. Call the phone number on your Membership Card to find out what services your health plan covers.

How do I get care for a substance abuse or addiction problem?
Check your Evidence of Coverage, or call your health plan to see if substance abuse problems are covered. Substance abuse is not one of the conditions that must be covered under the California Mental Health Parity law. However, substance abuse or addiction problems are probably covered if you are enrolled in small group coverage for 100 or fewer employees or if you purchased individual coverage for yourself or for your family. Medi-Cal also covers treatment for substance use disorders. If you have coverage for substance abuse disorders, ask your doctor to refer you for treatment or ask your health plan if you can see a mental health care provider without a referral. Ask for a list of providers.

What if the medicine I need is not covered?
Ask if there is a similar drug that is covered that you can try. See prescription drugs. If your doctor thinks you need a drug that is not covered, your doctor must make a special request to your plan. If your plan still says you cannot get the drug, you can file a complaint with your health plan.

Does the California Mental Health Parity Law cover children?
Yes. California’s mental health parity law requires coverage for the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age and serious emotional disturbances of a child. California law also requires all plans to cover behavioral health treatment for autism or pervasive development disorder, which is frequently identified during childhood.  Children with mental health or substance use disorders that are enrolled in individual or small group (100 or fewer employees) coverage may also obtain additional inpatient and outpatient treatment services; please see the information on this additional coverage, described above

Will my health plan cover residential treatment?
Plans must cover medically necessary residential treatment for any severe mental illness, serious emotional disturbance of a child, and for other conditions that are identified as a mental disorder. A residential treatment center provides long-term treatment and 24-hour supervision for individuals requiring ongoing and a more structured therapy environment. It is usually less restrictive than a psychiatric hospital.

A few questions to ask your provider or your health plan include the following:

  1. How long could residential treatment last?
  2. Is residential treatment covered for my mental health condition?
  3. What will I have to pay?
  4. Where is residential treatment provided?
  5. What are the names of contracted facilities?

You will need prior approval from your health plan before you or a family member receives residential care treatment. If your plan says the treatment is not medically necessary, you can file a complaint with your health plan.

What if I have Medi-Cal?
Medi-Cal provides mental health care and substance use disorder services. If you are in a Medi-Cal managed care plan, call your plan or call the Medi-Cal Mental Health Care Ombudsman at 1-800-896-4042.

What if I have Medicare?
Call your health plan and ask what mental health care services it covers. The California Mental Health Parity Law and the federal MHPAEA do not apply to Medicare plans.

Mental Health Resources