Arizona Coalition for Insurance Parity

Mental Health Parity Story Collection Form

Have you or someone you know been denied coverage for mental health or substance use disorder treatment in the state of Arizona? If so, the Arizona Coalition for Insurance Parity wants to hear from you.

The Arizona Coalition for Insurance Parity is collaboration between the Arizona Council of Human Service Providers, JEM Foundation, Mental Health America of Arizona, and the Neighbors Council. We are working to ensure that Arizonans are able to easily access appropriate and timely mental health and substance use disorder treatment through their medical insurance.

Please fill out this survey if you, or someone you know, has been unable to access needed behavioral health services or had a claim denied for mental health and/or substance use disorder treatment. The information you provide will help us to shape public policy and influence legislation in order to move us towards full parity implementation and mental health equity.

By completing this survey you are acknowledging that your information is being collected to help understand the current trends and circumstances surrounding mental health and substance use disorder treatment claim denials in Arizona. All information you provide will be kept confidential, and any identifiable information you choose to provide will not be shared without your permission.

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* 1. The story you are sharing may be about yourself or may be about someone you know well. If you are sharing a story on behalf of someone else, are you:

A parent

Other relative

A friend

A therapist or other mental health provider

A teacher or other school employee

I am sharing my own experience

Other (please specify)

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* 2. If you are sharing a story on behalf of someone else, please respond to the questions below from the perspective of the individual impacted.

Are you (Check all that apply):

A student

A veteran

Currently employed

Currently in the military

Federal employee

Member of a union

Retired

State or local government employee

Unemployed

Other (please specify)

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* 3. Age:

0-9

10-17

18-25

26-35

36-45

46-55

56-64

65 and over

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* 4. Gender:

Female

Male

Non-binary/third gender

Prefer not to answer

Prefer to Self Describe

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* 5. What county do you live in?

Apache

Cochise

Coconino

Gila

Graham

Greenlee

La Paz

Maricopa

Mohave

Navajo

Pima

Pinal

Santa Cruz

Yavapai

Yuma

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* 6. What is your home zip code?

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* 7. What issues were you having that caused you to seek mental health or substance use disorder treatment? (Check all that apply):

Autism Spectrum Disorder

Bipolar Disorder

Concerns with alcohol and/or drug use

Difficulty focusing on tasks

Difficulty managing anger

Difficulty managing anxiety

Domestic Violence

Eating Disorder

Feelings of depression

Hearing or seeing things that others do not hear or see

Loss of contact with reality

Not able to take care of myself

Obsessive-compulsive thoughts or behaviors

Panic attacks

Personality Disorders

Post-Traumatic Stress Disorder

Problems at school

Problems with my marriage

Relationship Issues

Schizophrenia

Severe shifts in mood, energy, and/or energy level

Sexual assault or molestation

Suicidal thoughts or attempts

Trauma history

Other (please specify)

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* 8. What help were you hoping to receive? (Check all that apply)

Autism Services (behavior coaches, ABA therapy)

Group Mental Health Therapy or Counseling

Individual Mental Health Therapy or Counseling

Inpatient Hospitalization – Emergency Room

Inpatient Hospitalization – Mental Health Hospital

Inpatient Residential Treatment Facility

Intensive Outpatient Services (day treatment, evening care)

Medication Assisted Treatment (MAT)

Ongoing Support or Pro-Active Support (psychiatrist and/or therapist)

Other Outpatient Services

Outpatient Substance Use Disorder Treatment

Partial Hospitalization

Peer and/or Family Support Services

Prescription Drugs

Testing by Mental Health Professional

Treatment by an Addiction Specialist

Withdrawal Management (e.g. detox)

I’m not sure

Other (please specify)

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* 9. What is the name of your insurance company?

Aetna

All Savers

Ambetter

Banner

Blue Cross/Blue Shield

Bright Health

Cigna

Health Net

Humana

Medicaid

Medicare

National Health

Oscar Health Plan

TRICARE

United Healthcare

WMI Mutual

I’m not sure

Other (please specify)

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* 10. What type of insurance plan do you have? (HMO, PPO, High Deductible Plan, or other?)

HMO

PPO

High Deductible Plan

I’m not sure

Other (please specify)

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* 11. Have you received any of the care you were seeking or requesting?

Yes, I received everything I sought/needed

No, I did not receive any of the care I sought/needed

Some, but not all of the care I sought/needed

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* 12. If you answered "no" or "some", what services didn’t you receive? (Check all that apply)

Autism Services (behavior coaches, ABA therapy)

Group Mental Health Therapy or Counseling

Individual Mental Health Therapy or Counseling

Inpatient Hospitalization – Emergency Room

Inpatient Hospitalization – Mental Health Hospital

Inpatient Residential Treatment Facility

Intensive Outpatient Services (day treatment, evening care)

Medication Assisted Treatment (MAT)

Ongoing Support or Pro-Active Support (psychiatrist and/or therapist)

Other Outpatient Services

Outpatient Substance Use Disorder Treatment

Partial Hospitalization

Peer and/or Family Support Services

Prescription Drugs

Testing by Mental Health Professional

Treatment by an Addiction Specialist

Withdrawal Management (e.g. detox)

I’m not sure

Other (please specify)

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* 13. If you answered "no" or "some", why haven’t you received the full care you were seeking? (Check all that apply)

I could not get an appointment.

The wait time was too long.

I could not find a provider close enough that I could get there easily.

I gave up because I got frustrated trying to arrange for or find care.

I could not find a culturally appropriate provider.

I could not find a provider able to communicate with me in my preferred language.

There is no provider who will take my insurance or was in my insurer’s network.

My insurance does not cover providers that are out of the network.

My insurance does not cover mental health or substance use disorder treatment.

My insurance limited the number of days of inpatient care I was eligible to receive.

My insurance refused to pay and I could not cover the out of pocket costs.

My insurance refused to pay for additional days of inpatient care recommended by my doctor.

My insurance told me that I needed to try a different type of treatment first.

Other (please specify)

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* 14. If your insurer denied your claim or request for services or did not pay for it, what was the explanation? (Check all that apply)

My plan excludes this coverage/it is not a covered benefit.

My plan limits the number of visits for this service.

My plan claims that the care was not medically necessary.

I did not get prior-authorization or prior approval for this service.

My provider/facility was not in network

The treatment was considered experimental

I don’t know

Other (please specify)

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* 15. If you were denied care, have you filed an appeal or complaint with your insurance company?

Yes, I have filed an appeal or complaint

No, I have not filed an appeal or complaint

Yes, the provider filed an appeal or complaint for me

I’m not sure

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* 16. If you were denied care, have you filed a complaint with the Arizona Department of Insurance?

Yes, I have filed a complaint

No, I have not filed a complaint

Yes, the provider filed a complaint for me

I’m not sure

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* 17. Would you be interested in publically sharing your story to help improve mental health and substance use insurance coverage? This means that someone from the Arizona Coalition for Insurance Parity might be contacting you.

Yes

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* 18. If yes, please provide your name, phone number, and/or email address so we can contact you.

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* 19. In your own words, tell us about your experience. Please do not include identifiable information, such as names, addresses, social security numbers, etc.

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* 20. To file a complaint with the Department of Insurance, please visit their website: https://insurance.az.gov/consumers.

If you would like more information on insurance parity and your rights, please visit www.DontDenyMe.org.

If you have questions about this survey or mental health parity, please contact Amy Meyertholen, Arizona Council of Human Service Providers, amy@azcouncil.com or fax 602.252.8664.

Thank you for helping us to gather information about access to mental health and substance use disorder treatment.

Arizona Coalition for Insurance Parity

Mental Health Parity Story Collection Form

Question Title

* 1. The story you are sharing may be about yourself or may be about someone you know well. If you are sharing a story on behalf of someone else, are you:

Question Title

* 2. If you are sharing a story on behalf of someone else, please respond to the questions below from the perspective of the individual impacted. Are you (Check all that apply):

Question Title

* 3. Age:

Question Title

* 4. Gender:

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* 5. What county do you live in?

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* 6. What is your home zip code?

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* 7. What issues were you having that caused you to seek mental health or substance use disorder treatment? (Check all that apply):

Question Title

* 8. What help were you hoping to receive? (Check all that apply)

Question Title

* 9. What is the name of your insurance company?

Question Title

* 10. What type of insurance plan do you have? (HMO, PPO, High Deductible Plan, or other?)

Question Title

* 11. Have you received any of the care you were seeking or requesting?

Question Title

* 12. If you answered "no" or "some", what services didn’t you receive? (Check all that apply)

Question Title

* 13. If you answered "no" or "some", why haven’t you received the full care you were seeking? (Check all that apply)

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* 14. If your insurer denied your claim or request for services or did not pay for it, what was the explanation? (Check all that apply)

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* 15. If you were denied care, have you filed an appeal or complaint with your insurance company?

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* 16. If you were denied care, have you filed a complaint with the Arizona Department of Insurance?

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* 17. Would you be interested in publically sharing your story to help improve mental health and substance use insurance coverage? This means that someone from the Arizona Coalition for Insurance Parity might be contacting you.

Question Title

* 18. If yes, please provide your name, phone number, and/or email address so we can contact you.

Question Title

* 19. In your own words, tell us about your experience. Please do not include identifiable information, such as names, addresses, social security numbers, etc.

Question Title

* 2. If you are sharing a story on behalf of someone else, please respond to the questions below from the perspective of the individual impacted.

Are you (Check all that apply):