Mental health care coverage: what your plan covers

Some plans do require a referral from your primary care physician to see any specialist, including a mental health provider. However, many plans do not require a referral, meaning you can access a therapist directly. You can find an in-network mental health provider by using our Find a Provider tool. 

Couples therapy coverage varies by plan, but coverage typically does not extend to couples therapy for general relationship challenges or communication issues. In some cases, a plan may cover couples therapy if one or both individuals has a diagnosed mental health disorder and the therapy is deemed medically necessary.

Prior authorization (PA) is a term that communicates to your provider the need to submit a request for your treatment. PA is needed for some outpatient treatment and all partial hospital, residential, and inpatient treatment. The provider you choose for treatment will request prior authorization on your behalf – you do not need to do this. Our Utilization Review Team will review the request to ensure that the treatment is medically necessary. If there are questions, concerns, or more information needed – we will work directly with your provider to coordinate.

Transcranial Magnetic Stimulation (TMS) is covered by most Priority Health Commercial, Individual MyPriority, and Medicare plans. Prior Authorization is required. For more information, please call 800.673.8043 (TTY 711) to speak with a behavioral health specialist.

If you have Priority Health Medicaid, please inquire about this level of care with your local Community Mental Health Center.

Electroconvulsive Therapy (ECT) is covered by most Priority Health Commercial, Individual MyPriority, and Medicare plans. Prior Authorization is not required when the outpatient treatment physician is in network with Priority Health. If the outpatient treatment physician is out of network with Priority Health, Prior Authorization is required. In addition, Prior Authorization is required when the treatment is being done while you are inpatient at an in or out of network facility. For more information, please call 800.673.8043 to speak with a behavioral health specialist.

If you have Priority Health Medicaid, please inquire about this level of care with your local Community Mental Health Center.

For medication questions, please call Customer Service using the number on the back of your member ID card or call 800.942.0954 and follow the prompts to speak with staff in the Pharmacy Department.

If you have an out-of-network benefit, you may be able to see a provider or receive treatment from an out-of-network facility. Be aware that out of pocket costs may be higher when the provider does not hold a contract with Priority Health. You may end up paying more out of pocket and/or paying for services that Priority Health does not cover. This is referred to as balanced billing (see below question for more information).

Another advantage of staying in-network is that your health plan works with participating treatment centers to ensure that they are providing evidence-based treatment.

Our Find a Doctor tool is a great way to search online for individual behavioral health providers that are in network in your area. This information is also available over the phone by calling the Behavioral Health Department at 800.673.8043 (TTY 711).

When you go out-of-network, you run the risk of being charged more than the reasonable and customary guidelines followed by Priority Health. The out-of-network provider/facility is not held to a contract and can bill you for the difference between what the treatment cost at their office/facility and what the insurance company paid. Staying in-network can help you avoid those additional costs. If you have more questions about balance billing, call 800.673.8043 (TTY 711) to speak with a behavioral health specialist.

Virtual visits, or teletherapy, are video- or phone-based therapy or psychiatry appointments, rather than in-person. Many mental health providers offer virtual visits for talk therapy and psychiatry. Many health benefits cover virtual visits the same way they cover in-person visits for mental health treatment.

You can find an in-network mental health provider that offers virtual visits by using our Find a Provider tool and filtering for virtual visits.

There are several options for mental health and substance use treatment. Choosing the right type of care for your needs depends on the intensity of treatment you are seeking, your treatment goals, and your diagnosis or symptoms.

These are the common types of care available for mental health treatment:

Your coverage may vary depending on the type of care you receive. For questions about your coverage, call the Behavioral Health Department at 800.673.8043 (TTY 711).

Community Care Management is a supportive mental health service offered to Priority Health members who are transitioning from an inpatient facility or partial hospitalization, or those who can benefit from more frequent mental health or substance use treatment. Members who take part in this program get a custom care plan with up to three visits per week, psychiatric support for medication management, help with the transition to ongoing outpatient care, and assistance with transportation, housing and community resources.

The program allows you to see a clinician more frequently (up to 3 three times weekly) at home, in the community, in an office, or virtually. There are some program restrictions based on plan and location. For more information and eligibility questions, contact our Behavioral Health Department at 800.673.8043 (TTY 711).

Download our Community Care Management flyer for more information.

What is it?

This service provides a therapeutic space to process thoughts, feelings, and behaviors while gaining skills for healthy coping. Outpatient therapy allows you to receive treatment while remaining at home or in the community. Sessions can occur weekly, bi-weekly, or monthly and focus on an array of concerns including coping with symptoms of a substance use disorder, understanding the disorder, relapse prevention, building self-esteem, gaining insight into relationships, dealing with strong emotions, or coping with a traumatic or life altering event(s). Many providers offer this service virtually as well as in person.

What types of clinicians provide this service?

• Licensed Professional Counselor
• Psychiatrist
• Clinical Social Worker
• Psychologist
• Licensed Marriage and Family Therapist.

For more information about how these providers differ in treatment, expertise, and training – click here: National Alliance on Mental Illness - Types of Providers

How long will I be in outpatient therapy?
The length of time spent in outpatient therapy will depend on the severity of your symptoms and how quickly goals are met.  You are encouraged to have regular conversations with your provider about how the process is going and what next steps may look like.

What is it?

This service provides a therapeutic space to meet with a clinician for a psychiatric evaluation. They help determine a diagnosis, and can prescribe psychiatric medication to help manage symptoms if needed. The frequency of visits is based on your level of need and medication monitoring guidelines. Many providers offer this service virtually as well as in person.

What types of clinicians provide this service?

• Psychiatrist
• Nurse Practitioner
• Physician Assistant

For more information about how these providers differ in treatment, expertise, and training – click here:

National Alliance on Mental Illness - Types of Providers resource.

This service is like outpatient therapy, but more intensive and frequent. Often the treatment is five days per week, up to three hours a day; however, some programs are more flexible.

What types of clinicians provide this service?

This level of care is provided by an outpatient group practice or outpatient clinic which can be staffed with several different types of clinicians.

How long will I be in intensive outpatient therapy?

Treatment in this level of care can last five to eight weeks – and could be longer depending on your clinical needs.

What is it?

This service is often referred to as “day treatment” and is the most intensive service that is offered on an outpatient basis. Treatment includes individual therapy, group therapy, and access to a clinician who can manage psychiatric medications if needed. Treatment will occur five days a week for six hours each day.

What types of practices provide this service?

This level of care can often be found at an inpatient hospital or an outpatient clinic.

What is it?

This service provides a supportive living environment alongside an intensive treatment program with access to individual and group therapy, psychiatric medication management, and other supports. Residential programs are often separated by whether they treat primary mental health or substance use concerns. Some residential treatment centers are specifically focused on the treatment of eating disorders.

What types of programs provide this service?

Most mental health residential programs are not connected to a larger hospital system, but will have medical staff available 24/7.

How do I find out what facilities are available for this level of care?

We strongly encourage you to contact the Behavioral Health Department at 800.673.8043 (TTY 711) to speak with a Behavioral Health specialist to navigate treatment options and facilities.

How long will I be in a residential program?

Treatment length depends on multiple factors and can vary. The initial authorization is based on a review of your presenting symptoms that is sent to Priority Health by your provider. Regular reviews by our clinical team are completed throughout the treatment stay to determine whether additional days are medically necessary.

If you are not satisfied with the coverage decisions made for your treatment, you or the provider can file an appeal. Learn how to file an appeal.

What is it?

This service is the most intense level of care and provides stabilization for someone who is experiencing an acute mental health concern and requires 24/7 monitoring in a locked facility.

What types of programs provide this service?

Some hospitals and stand-alone programs offer this care.