Pre-authorization for outpatient mental health (therapy)

Healthfirst Bronze Leaf Premier (marketplace)

New York, NY 10016

Hello,

I’m trying to find out if what my health plan is requiring is correct.

I recently switched healthcare plans but stayed with the same carrier (Healthfirst – “HF”). I’ve been seeing the same therapist weekly for 2.5 years (out patient) for general mental health care. This was a covered service/in network under my previous plan (also marketplace) and did not have a pre-authorization requirement.

When I reviewed the SOB, it states that pre-auth is required for *some services. I called HF to find out if that applies to outpatient therapy and they said ‘Yes, your provider needs to get pre-authorization from us before care is covered, in the form of a letter with a statement of “medical necessity” and copies of my medical records for review’.

My therapist and the billing manager of the office both are confused by this request, saying they don’t have to do that normally NOR have they had to for other HF patients. I called the insurance company back for clarity and they told me the same thing again.

This is delaying me continuing care as I don’t want to pay out of pocket for my visits in the meantime and my therapist is just confused. I’m also hesitant to allow HF access to my mental health records, it feels like an invasion of privacy.

I also found this on healthcare.gov: “This generally means limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The limits covered by parity protections include..Care management — like being required to get authorization of treatment before getting it” which reads to me like I don’t need pre-auth.

Do the insurance reps not know what the hell they’re talking about? How do I resolve this?