What You Need to Know About Insurance and Court-Ordered Behavioral Health

By The Legal Aid Society

New York and federal law requires health insurance – including Medicaid, Child Health Plus, and private insurance – to cover most court-ordered behavioral health treatment when medically necessary.

What is medical necessity?

It means that your doctor (and/or other medical professionals) says that the treatment is necessary to treat your mental health challenges or substance use disorder. Because your treatment was ordered by a court or a diversion program, your insurance should find that the treatment automatically fulfills this standard.

What types of services are covered?

Your health insurance will cover a variety of court-ordered inpatient, outpatient, and residential mental health and substance use disorder treatment, including:

• Detoxification and crisis intervention services in a hospital;
• Inpatient care in a hospital, inpatient rehabilitation, or residential treatment facility;
• Outpatient care in clinics and doctor’s offices; and
• If your health insurance includes prescription drug coverage, outpatient methadone treatment including suboxone and subutex.

You have the right to request coverage of these services, and if you are denied, you have the right to appeal the denial. You should act quickly because there are time limits on filing an appeal.

What if I am uninsured?

The New York Office of Alcoholism and Substance Abuse Services (“OASAS”) and the Office of Mental Health (“OMH”) have funds to meet the cost of court-ordered behavioral health services that are not paid for by insurance.

Remember, even though your treatment was ordered by a court or diversion program, you still maintain basic rights regarding your treatment, such as:

• The right to be free from abuse and mistreatment by employees;
• The right to participate in the development of your individualized service plan;
• The right to bring questions or complaints to the provider or third parties; and
• The right to refuse treatment and be told what effect this could have on your health or status in the program.

Disclaimer

The information in this document has been prepared by The Legal Aid Society for informational purposes only and is not legal advice. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. You should not act upon any information without retaining professional legal counsel.