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Information for Consumers

Information for Consumers

Consumers

As a consumer, there are times when you need assistance recognizing and navigating your mental health and substance use disorder benefits. The information below can help.

Understanding Your Benefits

Understanding the type of plan you have will help you determine your mental health and substance use disorder benefits. Before utilizing your mental health and substance use disorder benefits it is important to understand where your insurance comes from and what coverage is available under your plan.

If you are unsure if your plan offers mental health and substance use disorder benefits you can:

  • Check the certificate of coverage issued by your insurer or provided by your employer
  • Contact your human resources office
  • Contact your insurer directly (there should be a telephone number on the back of your insurance card) 
  • Contact your insurance agent
  • Contact ODI’s consumer hotline at 800-686-1526

You can also use this coverage chart to help you determine what type of coverage you may have under your health plan.

Helpful Questions to Ask Your Health Insurance Provider

  1. Is there a specific list of diagnoses and services that are covered under my plan?
    • Follow -up: Does my plan offer coverage for substance use disorders? If so, is Medicated Assisted Treatment like Suboxone (Buprenorphine), Methadone or Vivitrol covered?
    • Follow-up: Does my plan include coverage for Autism benefits? If so, is Autism considered a medical or behavioral health condition?
  2. What are the financial responsibilities like deductible and copayments that are associated with the type of service or level of care I/my dependent is seeking?
  3. Do I have benefits if I seek providers outside of network (out-of-network benefits), if so will these services cost more? Or does my plan require me to go to a specific provider in-network?
  4. I/my dependent has/have been diagnosed with or suspected to have (insert name of condition). Are there any limitations/exceptions to these or any related conditions?
  5. Does my plan require prior authorization or a referral from a physician for the type of service and level of care I am seeking?
  6. What are my/dependent’s benefits for prescription drugs treating behavioral health? Does my plan require me/my dependent to try generic drugs first before brand name?
  7. What should I do if I/my dependent gets a bill or is denied a service that should be covered under my behavioral health benefits?

Click the link for a printable version of Example Questions to Ask Your Health Insurance Provider

Filing a Consumer Complaint

If you have a question or concern about your mental health and substance use disorder benefits or if you are unable to resolve a complaint with your insurer you can file a consumer complaint with our Consumer Services Division (CSD). When you file a complaint, CSD will identify if your health plan handled your issue appropriately and within the terms of the policy or certificate of coverage.

When you are ready to file a complaint, it will be helpful if you have the following information handy: 

  • The name of your health plan 
  • Your policy number, group number if applicable (that is the unique identifier that attaches a policy to a specific individual and this number can be found on our insurance ID card)
  • A description of what happened and who was involved 
  • If the complaint involves a dependent under family coverage, identify the person named on the policy
  • Include any corresponding letters you have or that the company has sent you related to the dispute.

You can file a consumer complaint by: 

For additional information on filing a consumer complaint: 

Individuals with a self-insured plan can file a complaint with the U.S. Department of Labor by calling 859-578-4680 or by visiting www.DOL.gov

Individuals who receive Medicaid benefits can file a complaint with the Ohio Department of Medicaid by calling the consumer hotline 800-324-8680 or by visiting www.medicaid.ohio.gov

Appealing a Claim Denial

If you disagree with a decision made by your health plan regarding any claim denial, or reduction in benefits, often referred to as an adverse benefit determination, you have a RIGHT to appeal that decision under Ohio Law. For example, this could include benefit denials, prior authorization denials, and reductions in the length of stay for an inpatient facility. If you have received a decision like this, you can appeal.

To begin the appeals process, notify your insurance company that you want to appeal.  The initial appeal is conducted internally by the insurer. If your insurer upholds its original determination and you would like the matter further investigated, notify your insurance company that you want to appeal to the Ohio Department of Insurance (also referred to as "external review").  Once you notify your insurer that you want an external review, they will send all the necessary paperwork to the department to begin the process. Once the external review is completed, you will be notified that a final determination has been made.  External reviews are binding on the insurance company.

If you are experiencing an emergency and your life is in serious jeopardy or you are unable to regain function if treatment is delayed, you can request an expedited review by calling your insurance company.

To learn more about how to appeal a decision by your insurance company, visit the Understanding Health Coverage and the External Review Appeals Process webpage

To learn more about what to do if your health insurance provider denies your claim, read the Health Insurance Appeal Process handout created for you by the Ohio Department of Mental Health and Addiction Services, Recovery Ohio, and the Ohio Department of Insurance.