Expert Tips for Navigating Insurance Coverage for Behavioral Health

The New York State Office of Addiction Services and Supports, or OASAS, provides this podcast as a public service. Thoughts and opinions expressed do not necessarily represent or reflect those of the agency or state. This is Addiction, The Next Step. Hello once again, it's Jerry Gretzinger here at the State Office of Addiction Services and Supports in our studios with another episode of Addiction, The Next Step. I want to thank you for checking us out today and we're going to be talking about something really important and useful to a lot of our listeners. I think, you know, millions of Americans do struggle with mental health issues or substance use disorders. And, you know, it takes a lot for people to reach out looking for support and services that are available. But what if the system has roadblocks to those supports and services, right? What do you do to get around those? In 2022, a White House brief found that 29% of adults don't even know where to turn for the mental health care that they're looking for and need. And that is where something called CHAMP comes in to help alleviate some of those roadblocks. Joining us now to talk more about what that is, what those challenges are and how CHAMP helps is Ryan Gallagher. Ryan, thanks for sitting down with us. Yeah, thank you for having me. So, you know, let's start. We talk about, well, actually, let's start with the very beginning. I said CHAMP, right? So let's break that down for you. What does CHAMP stand for? Stands for a lot of things. But, you know, the acronym is Community Health Access to Addiction and Mental Health Care Project. All right. All the letters in there. That's right. It's what breaks it all down to CHAMP. And CHAMP really is a champion for people who need help getting through these roadblocks. So let's talk about what those are, right? You know, we want to believe that services and supports are available and that they're easy for everyone to access, but not always the case. Yeah. Well, I mean, the services and supports are there, right? But for a lot of people, and it makes a lot of sense, it comes down to cost, right? And one of the ways we fund our treatment and care is through insurance or health insurance. It's key to a lot of different things. And so CHAMP is here to make sure that insurance doesn't stand in the way, right? It makes it so people have that affordable access to care for their insurance. So I mean, so what does that mean for people? A lot of people know if they've got insurance, they just assume, okay, well, I have insurance. It's going to do what it's supposed to do. It's going to be equitable coverage for me, for anybody else, or different kinds of care that I'm seeking. But again, something that's not always the case, right? CHAMP takes a closer look to make sure they're getting what they deserve and that it's equitable. Sure. Yeah. I mean, I think if you've ever had a healthcare issue, whatever it may be, we all interact with our insurance companies, right? And it can be confusing, right? There's a lot of different rules in places, a lot of different places to turn to. Some providers are covered by your insurance. Some are not. There's different types of treatment that are covered. Some things are not. And, you know, it can be really overwhelming, especially people that we're serving, right? Going through a substance use disorder or mental health issues, they have a lot on their plate, right? And so adding on top of that, all the insurance issues, it can be really disheartening, right? And so we don't want that to be a roadblock for people. We want to be there for them and help them navigate all that. So we can, you know, one very major step, make sure they have insurance. A lot of people don't have insurance, you know? And so we help people, you know, get connected to the resources to find insurance. And then once you are sure that they have that, make sure that they can find providers underneath that insurance that accepts that care. And then if they have a provider, the treatment, treatments aren't always covered. Your provider, your doctor may say, hey, I think this is going to be the right thing for you. I think this is going to be the right step. And they have to get approval from the insurance companies. Sometimes that works. Sometimes it doesn't. And so we have to talk to them about that and help them navigate that process. Now I just want to point out too, because we've talked about this many times in the past, that when it comes to insurance coverage and what people are eligible for, you know, we said we have our addiction treatment centers across the state of New York and I don't want people to confuse it. You know, we do say, and it's true that someone's acceptance into one of these treatment centers is not based on an ability to pay. If you have an inability to pay, you are still able to get support and services that you're looking for. But in the cases where someone is eligible for insurance coverage to help with the costs, again, that's where CHAMP comes in, right? Because sometimes people don't even know the services that they're eligible for. And when I say services, I'm talking about like health insurance services, coverage, that kind of thing. Yeah, no, exactly. You know, and I want to make clear that it's not just, CHAMP is not just for people who have insurance. Right. And like you pointed out, there are plenty of, plenty of services out there that people can turn to for help if they don't have insurance. So we talk to people about that. But if they can qualify for insurance, whether that's Medicaid, Medicare, commercial insurance, we're going to try and help them do that. But yeah, insurance itself, if they don't have that, if they don't qualify for that, there's plenty of treatment options out there. And I mean, and this covers, you know, where with OASIS, the Office of Addiction Services and Supports, but this is also something that applies to people who are looking for mental health services. And we talk about providers, and this even extends to pharmacies. If people have prescription medications that they should be taking and they're having trouble getting coverage, again, CHAMP says we can help with that. No, I think that's one of the unique aspects of CHAMP, right? It is a joint program between OASIS and OMH. And there are, you know, a myriad of players in this ecosystem, right? So we have substance use disorder providers, we have mental health providers, like you pointed out, the prescription pharmacy providers there. And so, you know, we're navigating all of those with you, right? And that's, I think, part of the key to CHAMP, right? We're kind of there for you all through all of those steps. Yeah, that's the OASIS mantra, right? Every step of the way. It's a good mantra. I mean, it is what it is. And, you know, we try to do that. We try to live by those words. Whatever somebody needs at any given time, wherever they're at, we're with them every step of the way, certainly. So what I want to do, if you don't mind, kind of walk us through sort of a real world scenario that somebody might find themselves in, where they can sit back and go, you know what, I could use help from CHAMP at this point. And I know one of the things you've mentioned before is parity, right? So if somebody's got coverage, but they're seeing different levels of it, I won't try to explain that. I'll let you talk about it. But what's that real world scenario that someone could see this come into play? Yeah, definitely. And I think before I get to it, let me explain parity a little bit. So parity, you know, actually, before I started this role, I had never heard someone use that word in real life, you know, but it really is just the opposite of disparity. And I think we're all familiar with disparity, right? Things being unequal. And so there are a set of laws out there called the behavior health parity laws, right, that are trying to make substance use disorder and mental health equal in parity with other types of medical care. So medical and surgical, that's kind of what they do. Now, the laws in place just want to know that they're making things equal doesn't necessarily mean that it's going to be good coverage, right? There are plenty of plans that are good, and they help people, but there are a few out there that people might not be happy with, right? So it's always something to keep in mind. They're making leveling the playing field, right? So what are some real world scenarios? Basic examples would be, you know, if you have an insurance program that is charging you a copay for $100 to go visit, like a psychiatrist, right, but at the same time, you're sick and you go visit your primary care doctor, they're only charging you $45 for a copay. That's unequal, right? And that, for me, would be a red flag of a parity violation, and that shouldn't be happening, right? So you can work with you and your insurance company and say, hey, this shouldn't be happening, right? A different kind of scenario would be you have a high deductible, like a $6,000 deductible, but it covers all benefits. Since it's equal, right, and it's treating everything the same, not a red flag, not a parity violation there, right? So it's when things are unequal are the kind of baseline examples. Now, I think thankfully a lot of, you know, champs entering its seventh year, so been around doing this for a little while, those kind of baseline examples aren't really happening anymore, but there's still a lot of different things going on, right? Parity involves a lot of different things like prior authorization, medical necessity criteria, first fail policies, fail first policies. And so they're a little bit more intricate, and that's why it's important that programs like champ exist, because we are experts, we've seen it, we know, you know, hey, this isn't right, right? And so we can kind of help people through that. Yeah, so I mean, it's like a resource for anybody who's going through this sort of situation, and they run into a coverage issue like this doesn't feel right, you know, it doesn't pass the smell test, if you will, champ can step in and say, yep, this is okay, or no, it's not. And here's, here's the way through it. So also with insurance, I know a lot of times people get worried about denials, you know, they have a request for coverage, and you know, they're afraid of getting the big no, yeah, something else that champ can advise on. Yeah, definitely. And for me, one of the most useful parts of it, right? You know, it turns out about 60% of adults don't know that they have the right to file an appeal, right when they have a denial, right? So when you get a denial from your insurance company, it's not just Oh, well, right, and that's that many times, quite often, you have the right to appeal that decision with the insurance company. And we can help with that. And I think this is where that Oasis model every step of the way comes into play, right? champ is not just a program that'll tell you, oh, file an appeal, and then leave you to do it, right? We will sit down with you, make sure you got the right paperwork from your insurer, right, write the appeal with you, and then file that appeal. And then, you know, check up you and say, Hey, did you hear back? How's it going? You know, did you win? Now? What's the next step? Let's, let's talk about that. Right. And then you continue to work with them through, of course. Yeah. And you know, I think that that's probably a huge benefit for people to know is available to them. Because you do you get those things where you've been denied. And very often, like you said, people may not know they can file an appeal. And if they do know they can file an appeal, where do you start? How do you how do you write this? I mean, you know, you hear that? It's like, well, I'm not a lawyer, I don't have all that information to figure out how I can, you know, advocate for myself. champ, champ will help you do that. Yeah, definitely. And not only that, you know, in addition to appeals, there's also complaints, right, which are a little different, right? And the complaints go to the regulatory body of the governing body, right and different types of plans of different governing regulation entities. But, you know, to me, that's also important, because the did not, the appeal will help change your denial, right? Hopefully, right? Um, the complaint kind of looks at it in a bigger picture, right? Because quite often what happens, you know, if you win an appeal, the insurance companies will say, Oh, well, um, you know, very sorry, that shouldn't have happened. It was a one time thing and, um, won't happen again. But finally, a complaint with the government, right, allows them to see, Hey, this is happening a lot, right? And it's not just one person, right? And so, you know, if that's the case, then, you know, they can start taking bigger steps, right, to make sure it's not happening to other people, too. So, uh, you know, let me ask you this question before we kind of get towards wrapping things up here. Do you feel enough people are taking advantage of champ? Because again, it sounds like it's a terrific resource. And it's the sort of thing where I feel you, you can't spread the word of it far enough, right? It's like, no, this is here. Take advantage of it. You know, there, there isn't a cost for this service. It's just here to help. Yeah, no, I mean, uh, you know, it is free, right? We don't have any kind of requirements and there's no income requirements. You don't have to have a certain type of insurance, right? So no cost, no insurance type. It's for everyone across the state. We have our statewide helpline and call into. We have nine different local CBOs. People can go into in person if they feel more comfortable speaking in person with CBO, tell people what it stands for. No, no, no. Uh, it's a community based organization. And so people can go and talk in person and, you know, we support all languages, of course. So, um, you know, do I think enough people are using it? I, I'm happy everyone who calls, but I want everyone who has going through this to know about us and to reach out to us. So whether it's yourself or a loved one or a friend, right. Um, I want people to know that this resource exists. That's easy as a phone call away. So why don't we make it even easier? Tell them the number, right? What, what can they do? You can call 1-888-614-5400. Okay. Give it to them one more time. Cause you know, somebody's whipping out a pencil. Of course. Yeah. 1-888-614-5400. Great. Right. And you know, we have information on the Oasis website as well. Um, and so hopefully that's what we hope for. That's why we're here. Thanks for sitting down and sharing this important information, Ryan. We appreciate it. Yeah. I thank you for having me. I really appreciate the opportunity to tell more people about you. That's what it's all about. And, uh, yeah, he mentioned the Oasis website. It's oasis.ny.gov. That's O-A-S-A-S dot N-Y dot G-O-V. Our hope line, obviously 877-8-HOPE-N-Y. That's all out there. It's resources for you, support services, everything we can do to help out and be there every step of the way. I'm Jerry Gretzinger. Thanks for joining us for this edition of Addiction, The Next Step. We will talk to you next time.