Anyone Can Get Treatment From A Behavioral Hospital, As Long As You Have The Right Insurance

Anyone that presents to a Behavioral Health Hospital (Inpatient Mental Health/Substance Abuse) is required to be assessed according to EMTALA (Emergency Medical Treatment and Labor Act). However, what happens after that will depend on many variables, including the resources you have.

According to CMS, Medical Necessity Criteria is 1) Suicidal ideation or gesture within 72 hours, 2) assaultive behavior threatening others within 72 hours of admission, 3) command hallucinations directing to harm self or others within 72 ours of admission. Translated into a live narrative the Medicaid MCO (Managed Care Organization) care managers will look for a patient to be "actively" suicidal, homicidal or psychotic with plan, intent and means. The patient must be actively and severely in need of services in order to presevere life and prevent harm to others. In the absence of these criteria, the Insurance will state that the patient does not meet medical necessity criteria.

Commercial or "private" insurance is much more human and lenient. It's members can present to the same hospital with what they describe as "functional impairment", where the member simply doesn't find the same joy from what they once did to meet criteria for Inpatient. This category could include how most of us ebb and flow in our level of functioning through hard times. However, if you happen to be covered through one of these plans, you can access this intense level of care that can greatly expedite your recovery.

As a caveat, even though the payer might not think that your symptoms meet their medical necessity criteria and as such, they will not pay for it, their is still an obligation to treat the symptoms. The Hospital is put at great risk because of the all of the liability they assume by not admitting the patient. Herein lies the complexity of the dance we do between the insurance provider, the patient presentation and level of care recommendation. Truth is, the hospital will often make recommendations that try to find the balance between the least restrictive level of care, what is medically necessity according to their payer and of course, what is best for the patient. The choices for treatment and care are relative to the types of resources your have.