Mental Health, Ghost Networks, & Access to Care Laws
There’s a term called “ghost networks” when it comes to mental health care because you think you have a “network” of providers to access mental health, but you go to your insurance company website & start calling providers from the list only to find out that the phone number is disconnected, every practice within a 50 mile radius is not accepting new patients / not replying, or there plain isn’t anyone that you can go to within the next 6 months. In New York City, good luck finding an in-network therapist! Other parts of the country, good luck finding a specialized therapist.
ACA marketplace, Medicare, & Medicaid plans require “network adequacy”. Note that most GROUP health insurance plans are NOT “ACA marketplace” plans. ACA Section 1557 might, in a longshot way, help… but I’m not a licensed attorney and someone else will have to carry forth that theory into litigation one day (if ever). Also, your individual state might have laws according to this network adequacy framework if you have a plan that is not ACA marketplace, Medicare, or Medicaid. Here’s a list: https://www.ncsl.org/health/health-insurance-network-adequacy-requirements. Note that some only apply to primary health, not mental health.
“Network adequacy” means that an insurance contract (that is one the 3 mentioned before, or one covered by your state) is required to provide an in-network provider (that is reasonably accessible) for treatment that they say is covered. So, FOR EXAMPLE, if there is no in-network therapist accepting new patients within a 50 mile radius with an open appointment within the next 6 months, then you can compel the insurance company to pay for treatment from an out of network therapist in your area. This sounds nice, but the mechanics can be painful.
If you believe you have a network adequacy claim, you must first get someone from the insurance company on the line. This may take 5-8 phone calls, and you will be transferred, disconnected, etc. You can try to speed this up by using the word “administrative grievance” or some synonym for that idea or the word “grievance”. Each insurance company has a different name for this same function. The “grievance” should explain that there are no in-network providers available for you to see, and via network adequacy laws that apply to your plan (remember, your plan might not be covered under network adequacy) and that you want the insurance company to pay for an out of network provider.
After that, the insurance company will try to “prove you wrong” and find providers that are in-network that can treat you. They may send you a list of 2-3 providers that satisfy their legal requirements. If one of those providers can see you, your journey ends there and you have to go to one of those providers. You can sue / try to further compel the insurance company, however, in my opinion the insurance company has the upper hand in this situation.
If the insurance company cannot prove you wrong and there are no in-network providers in your area, their next move will be to say, “we apologize for the inconvenience and are working on it”. If you request them to pay for an out of network provider, many companies will say, “we don’t do that” or “we don’t have a process for that” or something along those lines. You can tell them the legal statute, but their position will be a very polite, “so sue us / make me do it”.
At this point, you either have to file a lawsuit and litigate, file a complaint with your department of insurance, or contact your local elected official and try to get them to help. I recommend contacting your local official first and see if they can help. Regardless of which party that official is, most politicians will gladly score points making the big bad insurance company honor their contract. Next would be contacting your state insurance department. However, most insurance departments work FOR the insurance companies (in my humble opinion) so your mileage may vary. If that doesn’t work, I’m sad to say you must file a lawsuit. Maybe you can find a class action attorney who can make the lawsuit threatening enough to make the insurance company act quickly, but the process is a “game” from that point and your access to care means very little.
I write this not to discourage anyone, but to lay out how the system operates as of the time of this writing, so you can prepare for whatever course of action you intend to go.
