Addiction: The Next Step
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Addiction: The Next Step
Expert Tips for Navigating Insurance Coverage for Behavioral Health
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Struggling with the maze of insurance while trying to get mental health or substance use disorder care? You're not alone. Join us this episode as we promise to arm you with the knowledge and tools you need to navigate this complex terrain. We sit down with Ryan Gallagher to explore CHAMP, the Community Health Access to Addiction and Mental Health Care Project, and discuss how it’s making a tangible difference in people’s lives. Whether you need help securing insurance, finding in-network providers, or getting your treatments approved, CHAMP offers expert guidance and support, regardless of your insurance status.
We’ll break down the intricacies of behavioral health parity laws and debunk common myths surrounding insurance coverage. Learn how to spot and address parity violations, and understand why high deductibles can be misleading. Discover the vital role that CHAMP plays in helping individuals with prior authorizations, appeals, and even filing complaints with regulatory bodies. This episode is your essential guide to effectively advocating for your coverage rights and making the most of CHAMP's indispensable, free services. Don’t miss out on this empowering conversation that could change how you access mental health care.
Breaking Down CHAMP
Isabel ByonThe 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 .
Jerry GretzingerHello , 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 .
Jerry GretzingerJoining 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 .
Ryan GallagherYeah , thank you for having me .
Jerry GretzingerSo 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 ?
Ryan GallagherIt stands for a lot of things , but you know the acronym is Community Health Access to Addiction and Mental Health Care Project . Right , I have all the letters in there .
Jerry GretzingerThat's right . It's what breaks . It comes 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 .
Ryan GallagherYeah , well , I mean , the services and supports are there , right , but for a lot of people it makes a lot of sense comes down to cost , right , and one of the ways we fund our treatment and care is through insurance , our 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 . It makes it so people have that affordable access to care through their insurance .
Jerry GretzingerSo what does that mean for people ? 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 , you know , equitable coverage for me , for anybody else , for 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 .
Ryan GallagherSure , and ean , I think if you've ever had a health care 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 .
Ryan GallagherYou're already , 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 , very step make sure they have insurance .
Ryan GallagherA 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 we are sure that they have that , make sure that they can find providers underneath that insurance that accepts that care . And then , once they have a provider , the treatment right that they can find providers underneath that insurance that accepts that care . And then , once they have a provider , the treatment right . 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 .
Ryan GallagherSometimes that works , sometimes it doesn't , and so we have to talk to them about that and you know we can help them navigate that process .
Jerry GretzingerNow 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 .
Jerry GretzingerBut in the cases where someone is eligible for insurance coverage to help with the costs , again that's where CHAMP comes in right , bBecause sometimes people don't even know the services that they're eligible for . Yeah , and when I say services , I'm talking about like health insurance services , coverage , that kind of thing .
Ryan GallagherYeah , 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 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 .
Ryan GallagherIf they don't have that , if they don't qualify for that , there's plenty of treatment options out there still .
Jerry GretzingerAand this covers we're with OAIS , the OfficeS 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 .
Ryan GallagherYeah , no , I think that's one of the unique aspects of CHAMP right . It is a joint program between OASAS and OMH and there are , you know , a myriad of players in this ecosystem , right . So we have , you know , 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 through all of those steps .
Jerry GretzingerYeah , that's the OASAS mantra , right .
Jerry GretzingerEvery step of the way .
Ryan GallagherIt's a good mantra .
Ryan GallagherI mean , it is what it is
Jerry GretzingerAnd 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 ?
Ryan GallagherYeah , definitely , and I think . Before I get to it , let me explain parity a little bit . So parity ? Actually , before I started this role , I had never heard someone use that word in real life , but it really is just the opposite of disparity and I think we're all familiar with disparity right . Things being unequal
Navigating Insurance Coverage With CHAMP
Ryan Gallagher. And so there are a set of laws up 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 .
Ryan GallagherSo medical and surgical that's kind of what they go to now the laws in place .
Ryan GallagherUh , just want to note that they're making things equal . It doesn't necessarily mean that it's going to be good coverage , right ? Um , you know there are plenty of plans that are good and they 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 , when you're sick and you go visit your primary care doctor , they're only charging you $45 for a copay , you know that's unequal right and that for me would be a red flag of a parity violation and that shouldn't be happening , right .
Ryan GallagherSo 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 the baseline examples . Now , I think , thankfully a lot of you know CHhamp's 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 . Right , parity involves a lot of different things like prior authorization , medical necessity , criteria first fail , first fail policies , or fail first policies , and so they're a little bit more intricate . And why it's, ? 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 , like , and so we can kind of help people through that .
Jerry GretzingerYeah . 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 , Cp can step in and say , yep , this is okay or no , it's not , and 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 .
Jerry GretzingerSomething else that CHAMP can advise on .
Ryan GallagherYeah , definitely , and for me , one of the most useful parts of it right is it turns out about 60% of adults don't even know that they have the right to file an appeal when they have a denial . So when you get a denial from your insurance company , it's not just oh well and that's that . Many times and 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 OASAS model every step of the way comes into play .
Ryan GallagherCHhamp is not just a program that will tell you , oh , file an appeal and then leave you to do it . We will sit down with you , make sure you've got the right paperwork from your insurer , write the appeal with you and then file that appeal . And then check up with you and say , hey , did you hear back ? How's it going ? Did you win ? No , what's the next step ? Let's talk about that .
Jerry GretzingerRight , and then you continue to work with them through that . Of course , yeah , and you know , I think 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 write this ? I mean , 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 advocate for myself . CHAMP will help you do that .
Ryan GallagherYeah , definitely . And not only that , in addition to appeals there's also complaints , which are a little different , and the complaints go to the regulatory body of the governing body and different types of plans of different governing regulation entities . But to me that's also important because the appeal will help change your denial . Hopefully the complaint kind of looks at it in a bigger picture , right , because you know 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 , that was a one-time thing and um , won't happen again .
Ryan GallagherBut filing a complaint with the , 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 .
Jerry GretzingerSo 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 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 .
Ryan GallagherYeah , no , I mean , you know it is free , right . We don't have any kind of requirements . There's no income requirements . You don't have to have . You know a certain , you know type of insurance , right , it's so no cost , no insurance , you know type . It's for everyone across the state . We have our statewide helpline that people can call into . We have nine different local cbo's people can go into in person if they feel more comfortable speaking in person with your face at CBO .
Jerry GretzingerTell people what it stands for .
Ryan GallagherI'm sorry .
Jerry GretzingerNo , no , no .
Ryan GallagherIt's a community-based organization , so people can go and talk in person , and we support all languages , of course . So do I think enough people are using it . I'm happy with 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 ? I want people to know that this resource exists .
Jerry GretzingerThat's easy as a phone call away , so why don't we make it even easier ? Tell them the number right . What can they do ?
Ryan GallagherYou can call 1-888-614-5400 . Okay .
Jerry GretzingerGive it to them one more time , because you know somebody's whipping out a pencil .
Ryan GallagherOf course yeah , 1-888-614-5400 .
Ryan GallagherGreat , and you know we have information on the OASAS website as well , and so people hopefully can find that .
Jerry GretzingerThat's what we hope for . That's why we're here . Thanks for sitting down and sharing this important information , Ryan .
Jerry GretzingerWe appreciate it .
Ryan GallagherYeah , thank you for having me . I really appreciate the opportunity to tell more people about CHAMP .
Jerry GretzingerThat's what it's all about . And yeah , he mentioned the OASAS website . It's oasas nygov , that's O-A-S-A-S , dot N-Y , dot . G-Oo-v . Our HOPEline obviously 877-8-HOPENY . Wy '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 .
