9.7.23

This report is based on in-depth qualitative research that followed seventeen people covered by insurance plans purchased on state and federal marketplaces as they tried to find in-network mental health care providers.

None of the seventeen participants managed to schedule an appointment with an in-network provider that took place during the study, even though sixteen of them had been searching for providers even before the study began. They found the search process to be complex, time-consuming, and frustrating. Participants reported that searching and delays in getting care negatively affected their mental health, relationships, work or school, physical health, and finances. To increase access to mental health care, participants wanted insurers to cover more mental health care providers and to make out-of-network providers more affordable. They also wanted more streamlined processes for identifying in-network providers and to eliminate the need for referrals for mental health care.

The participants in this study were searching for mental health care providers because they had newly identified a need for mental health care, because they lost their employment and had to purchase coverage that their existing providers did not accept, or because the no-cost therapy sessions available under their existing plans ran out. Participants answered weekly structured prompts from October 11 to November 14, 2022, as they searched for providers, tried to figure out which were in network, obtained referrals when needed, and tried to schedule appointments. The methodology section of this report provides more information about how this study was conducted.

Key Findings

  1. None of the seventeen participants managed to schedule an appointment with an in-network provider that took place during the study. Sixteen of the participants had already been searching for a mental health care provider prior to the start of this study, including five who had been searching for six or more months. But none of them were able to schedule an appointment with an in-network mental health care provider that tookplace during the study.
  2. Six participants scheduled appointments, but only two believed that the mental health provider would be in network. Two participants scheduled appointments with mental health care providers that took place during the study. One of them knew the provider would not accept their insurance. The other believed the provider was in network, only to find out later they were not. Both had to negotiate prices for their out-of-network care. A third participant scheduled an appointment but had to cancel because the provider did not accept her insurance and she could not afford to pay out of pocket. Another three participants scheduled appointments that would take place after the study period. Two of them believed the provider would be in network, while the third was not sure whether or not they would be in network or not.
  3. The six participants who scheduled appointments had to make tradeoffs in order to do so. Of the six who scheduled, three believed they would have to wait too long for their appointment. One would have to travel over ninety minutes for their appointment. As noted above, only two believed that the provider they scheduled with would accept their insurance.
  4. The most commonly cited challenges in searching for mental health care were a lack of in-network providers and a lack of appointments available at workable times. Nine of the seventeen participants said they experienced difficulties finding a mental health care provider who accepted their insurance, including four who indicated it was a “chronic challenge,” i.e., they experienced it multiple weeks in a row during the study. The only other challenge cited as often was difficulty finding providers with appointments at workable times.
  5. Searching for in-network mental health care providers or delays in getting care negatively affected all participants, impacting their mental health, relationships, work or school, physical health, and finances. Most participants said their relationships with friends and family were affected, either because they diverted time from relationships to searching for mental health care or because worsening mental health symptoms strained relationships. Participants also reported challenging search processes and delays in getting it impacted their work, with some reporting losing their jobs or missing out on income. Even participants who scheduled appointments reported negative effects of searching and delayed care. Five participants were impacted across all five domains.
  6. For all participants, whether they scheduled or not, trying to find in-network mental health care was time-consuming, requiring them to piece together information across a variety of sources and speak with multiple providers. Participants’ described a continuous cycle of attempting to identify providers, understand their benefits, figure out whether providers were in network, obtain referrals, and book appointments. Some had to wait weeks for insurers or prospective providers to respond to questions or for appointments. Participants who had to obtain referrals from primary care physicians found that process time-consuming and frustrating, and questioned whether referrals should be necessary.
  7. Among the eleven participants who were unable to schedule appointments, few were confident they would find the right provider for them. Only two of the eleven who were unable to schedule were confident that they would find a mental health care provider who would be a good fit for them. The other nine were concerned about finding providers who were affordable, in convenient locations, had workable appointment times or who would be
    good fits culturally, linguistically, or interpersonally.
  8. Participants wanted better ways to identify in-network providers, questioned the necessity of referrals, and wanted insurers to cover more providers. Despite having access to their insurer’s directories, participants expressed a need for centralized, easy to find, accurate information that would help them identify in-network providers. Some participants suggested that referrals should not be required for mental health care because obtaining them prolongs the search process, creates stress, and necessitates scheduling and waiting for expensive primary care appointments. Many expressed a need for insurance networks to include more mental health care providers or at least offer some coverage for out-of-network care.