Quick answer: Often, yes. Federal law and Georgia’s 2022 Mental Health Parity Act require most health plans to cover mental health care on terms comparable to physical health care, including residential treatment when it’s medically necessary. What you’ll pay depends on your plan type and whether the program is in-network. Perry Behavioral Health is currently out-of-network with insurers.
How we put this guide together
Perry Behavioral Health is a residential mental health program in Perry, Georgia, for middle and high schoolers. We’re currently private pay and out-of-network with insurance companies, so we have a direct interest in how out-of-network coverage works. This guide explains coverage for any program you’re considering, using federal rules published by HealthCare.gov and Georgia’s Mental Health Parity Act. Every plan is different, so your plan documents and a benefits check are the final word.
How coverage works by plan type
| Plan type | Out-of-network coverage | Referral usually needed | What it means for teen residential treatment |
| PPO (Preferred Provider Organization) | Usually yes, at a higher cost | No | The most flexibility in choosing a program |
| POS (Point of Service) | Often yes, with conditions | Often yes | Check referral rules first |
| HMO (Health Maintenance Organization) | Usually no, except emergencies | Yes | Generally limited to in-network programs |
| EPO (Exclusive Provider Organization) | Usually no, except emergencies | No | Generally limited to in-network programs |
1. Federal law requires most plans to cover mental health care
Under the Affordable Care Act, all Marketplace plans must cover mental and behavioral health services, including inpatient behavioral health services, as essential health benefits. Most individual and small-group plans have the same requirement. Federal parity law also means limits on mental health care generally can’t be more restrictive than limits on medical and surgical care.
One exception to know: large employers that self-insure don’t have to provide the essential health benefits package, though parity rules still apply if they cover mental health care. Ask your HR department whether your plan is self-funded.
2. Georgia’s parity law adds protections
In 2022, Georgia passed the Mental Health Parity Act (HB 1013), which took effect July 1, 2022. It requires insurers to cover mental health and substance use disorders in line with federal parity law, and it requires medical necessity decisions to follow generally accepted standards of care rather than guidelines insurers write for themselves. The law also created a way for consumers to file complaints about suspected parity violations.
These state protections generally apply to state-regulated plans, while self-funded employer plans are governed by federal law.
3. Your plan type decides whether out-of-network care is covered
If a program is out-of-network, your plan type matters most. PPO and many POS plans pay for out-of-network care at a lower rate than in-network care. HMO and EPO plans usually don’t cover out-of-network care outside emergencies. Check your insurance card or call member services to confirm your plan type.
4. Out-of-network means higher costs, not lower-quality care
“In-network” means a program has a contract with your insurer. “Out-of-network” means it doesn’t. Network status is about pricing, not quality. Out-of-network care usually means:
- A separate, often higher, out-of-network deductible.
- Higher coinsurance, such as 30% to 50% of the allowed amount.
- A separate out-of-network out-of-pocket maximum, or sometimes none.
- Possible balance billing for charges above what your plan allows.
Ask your plan for each of these numbers so you can estimate your share.
5. Expect a medical necessity review
Most plans require prior authorization before covering residential treatment and review progress during the stay. Records from your teen’s therapist, psychiatrist, pediatrician or any recent hospital visit help show why a higher level of care is needed. Under Georgia’s parity law, these decisions must follow generally accepted standards of care.
6. You can appeal a denial
If coverage is denied, ask for the decision and the criteria behind it in writing. File an internal appeal with your plan, and if that fails, request an independent external review, which most plans must offer. Treatment programs and your teen’s clinicians can help supply documentation. If you believe your plan isn’t following parity rules, you can file a complaint with the Georgia Office of Commissioner of Insurance and Safety Fire.
7. Verify benefits before admission
A benefits check tells you what your plan covers and what you’re likely to owe. Have your insurance card, the policyholder’s name and date of birth, and your teen’s information ready. Ask:
- Does my plan cover residential mental health treatment for adolescents?
- Do I have out-of-network benefits, and is prior authorization required?
- What are my out-of-network deductible, coinsurance and out-of-pocket maximum?
- How does my plan set the allowed amount for out-of-network residential care?
- Is my plan fully insured or self-funded?
Perry Behavioral Health’s admissions team can walk you through benefit verification, private pay costs and what to expect. Call (478) 324-4948 or contact us online.
FAQ
Does insurance cover residential treatment for teens in Georgia?
Many plans do when residential treatment is medically necessary. Federal law and Georgia’s Mental Health Parity Act require most plans to cover mental health care on terms comparable to medical care. Your costs depend on your plan type, whether the program is in-network, and your deductible and coinsurance.
Does Perry Behavioral Health take insurance?
Perry Behavioral Health is currently private pay and out-of-network with insurance companies. Some plans, particularly PPO plans, may still provide out-of-network benefits. Our admissions team can help you verify your benefits and understand your costs before admission.
What is Georgia’s Mental Health Parity Act?
Georgia’s Mental Health Parity Act, HB 1013, passed in 2022, requires insurers to cover mental health and substance use disorders in line with federal parity law. It requires medical necessity decisions to follow generally accepted standards of care and created a complaint process for suspected parity violations.
Does Medicaid cover teen residential mental health treatment in Georgia?
Georgia Medicaid and PeachCare for Kids cover some behavioral health services for children and teens, but coverage for specific residential programs depends on whether the program accepts Medicaid. Ask any program directly whether it accepts Medicaid or PeachCare before admission.
What can I do if my insurer denies residential treatment?
Request the denial and the clinical criteria in writing, file an internal appeal, and if needed request an independent external review. Ask your teen’s clinicians for supporting records. If you think the denial violates parity rules, you can also file a complaint with Georgia’s insurance commissioner.