Carelon Behavioral Health Insurance Coverage for Mental Health
Understanding mental health insurance, especially at a time when you might be dealing with an issue like depression, anxiety, or trauma, can feel like learning a new language. You might find yourself first encountering Carelon Behavioral Health because it manages the mental health part of your health insurance, and you’re trying to get treatment. But suddenly you’re being asked about authorizations, networks, and levels of care, when you’re only trying to get the support you need.
The team at Mission Connection can assist you with understanding the ins and outs of Carelon Behavioral Health coverage, helping remove some of the pressures of the process. Our goal is make finding your way through insurance more manageable so you get the mental health care that truly fits your needs.
This page also works as a useful guide for Carelon mental health services, as it explores:
- What Carelon Behavioral Health coverage is
- The services Carelon typically covers
- What medical necessity is and how they determine it
- The difference between in-network and out-of-network providers
- Challenges sometimes encountered when using insurance
- Commonly asked questions about Carelon Behavioral Health
What Is Carelon Behavioral Health Coverage?
Carelon Behavioral Health is part of a wider health insurance company called “Elevance Health.”1 Most people don’t sign up for a Carelon plan specifically. Instead, Carelon works behind the scenes, managing mental health and substance use benefits for the larger insurance carriers and employer-sponsored plans.
In practical terms, Carelon oversees how mental health services are accessed and approved. This includes:
- Building networks of Carelon Behavioral Health providers
- Reviewing clinical information
- Determining what level of care is needed at a given point in time
Because Carelon Behavioral Health insurance functions as a third-party administrator, you might not even know you’re using it until you try to enter treatment. A third-party administrator means that Carelon is an independent company that performs the administrative tasks for a health plan, like billing, processing claims, and keeping records.2
So you might see your insurance card list a different provider, but route the behavioral health services through Carelon. To put it simply, Carelon basically manage the mental health benefits of your insurance coverage.
What Mental Health Services Does Carelon Typically Cover?
Carelon covers services from outpatient to inpatient and everything in between. But coverage is not the same for everyone. What’s available usually comes down to your health plan, clinical recommendations, and how Carelon (and your provider) determine medical necessity over time.
But depending on your needs, Carelon behavioral health insurance provides coverage of different levels of care, including:
Outpatient Services
Outpatient care is often where people start with treatment, especially if they’re looking for the least intense form. Outpatient services might include individual, family, or group therapy. They can also include mental health evaluations and medication management.
Outpatient care is the least intense because it is usually held once a week or every other week. For instance, you might attend a weekly session with a therapist or biweekly group sessions. As it’s only once or twice a week, you should be able to continue with work, school, and other responsibilities.
Structured Outpatient Programs
Carelon outpatient mental health treatment may offer more structured programs when weekly therapy isn’t enough. These programs include:
- Intensive outpatient programs (IOPs), which are usually around 20+ hours of treatment per week
- Partial hospitalization programs (PHPs), which are structured all day (five to seven hours) for up to five days a week, without needing a hospital or inpatient program.2
These programs offer multiple therapy sessions per week and a higher level of support, while you’re still able to return home each day.
Inpatient and Specialized Care
For some people, symptoms may become overwhelming, or there might be safety concerns. In these situations, Carelon may authorize inpatient mental health treatment. They may also cover specialized treatment needs, like:
- Carelon depression treatment
- Carelon anxiety therapy
- Trauma-focused care
- Eating disorders treatment
- Carelon dual diagnosis coverage for co-occurring mental health and substance use concerns.
Coverage decisions don’t often stay the same. As your symptoms shift and progress, Carelon reviews treatment on an ongoing basis and adjusts support to match what’s clinically appropriate at the time. This might mean moving down from inpatient to a PHP or moving up from outpatient to an IOP.
What Is Medical Necessity?
The phrase “medical necessity” can sound intimidating, especially when it’s tied to whether treatment is approved or continued. Basically, medical necessity is the term insurance companies use to determine the healthcare services that are appropriate, given a person’s condition, diagnosis, and current standard of practice.3
How Carelon Determines Medical Necessity
Like many health insurers, Carelon uses the medical necessity standard as a way to decide what level of mental health care is appropriate based on someone’s current needs. However, it’s not a judgment about whether those needs are valid.
To determine medical necessity, a clinical team provides information about:
- The severity of your symptoms
- How much these symptoms interfere with daily life
- Whether there are concerns related to safety, functioning, or stability
- Treatment history
Carelon looks at medical necessity on an ongoing basis, not as a one-time decision. As symptoms improve, shift, or become more complex, the level of care may change as well. For example, someone might begin with outpatient therapy, move into a structured program for additional support, and later step back down once things feel more manageable.
While the process can feel opaque from the outside, licensed clinicians handle these reviews using established guidelines. The goal is to align care with what’s clinically appropriate in the moment, not to create unnecessary barriers to Carelon mental health help.
In-Network vs. Out-of-Network Carelon Providers
When using Carelon behavioral health insurance, one of the first distinctions you’ll encounter is whether a provider is considered in-network or out-of-network. Knowing this difference can help you better understand possible costs.
Working With In-Network Providers
Having an in-network provider means that your insurance company, like Carelon Behavioral Health, has a contractual agreement with these providers. When you get treatment with an in-network provider, it usually means lower out-of-pocket costs, more transparent billing, and fewer steps required to start treatment. Many people find that starting with in-network care removes some of the friction that can come with scheduling therapy or entering a program.
Using Out-of-Network Care
Some plans allow for out-of-network mental health care, though it tends to involve more variables. Out-of-network coverage may include higher deductibles, partial reimbursement, or the need to submit claims after paying upfront. In these situations, the administrative side of care can feel heavier, especially when you’re already managing mental health concerns.
Common Challenges When Using Health Insurance
Even with Carelon mental health benefits in place, the experience of actually using them can feel more complicated than expected. Some of the challenges to be aware of are:
Authorization Requirements
Certain services, especially intensive outpatient programs or higher levels of care, often require approval before treatment begins. It’s important to know that sometimes getting approved for treatment can take time. This can feel discouraging when you’re ready for treatment and have to wait. We’ll work with you and your treatment provider to avoid this as best we can.
Shifting Coverage Over Time
Coverage can shift over time as symptoms improve or change. This usually means that health insurance may only approve care in phases rather than all at once, like approving inpatient care before approving an outpatient program. Approving in phases leaves treatment open to change as needed. But for some people, this creates uncertainty about how long treatment will last, even when it’s clearly helping.
Unclear Limits Or Expectations
Sometimes insurance companies are not clear on how many sessions you get or how many visits you’re allowed. Or the changing requirements are not always explained up front. These unclear expectations become a challenge because many people don’t realize these details until they’re already in treatment, which can make planning difficult.
Navigating Multiple Systems
Dealing with insurance sometimes means working through multiple systems. Because Carelon works alongside primary insurance providers, it’s not always transparent who handles which part of the process. Questions about billing, approvals, and benefits can bounce between systems, adding to the frustration of an already stressful time.
These challenges reflect how complex insurance systems can be, but they don’t mean Carelon insurance accepted therapy isn’t available or effective. It just explains why guidance and advocacy are so important.
Finding Support With Carelon Through Mission Connection
Navigating mental health care can be hard enough without having to decode insurance along the way. At Mission Connection, we work with you to make the process more manageable. Whether this means answering questions, verifying coverage, or talking through what level of care might be appropriate.
If you’re exploring therapy or treatment and wondering how your health insurance works, our team is here to help you find clarity and support. Reach out to Mission Connection to verify your coverage or start a conversation about care options that meet your needs.
Frequently Asked Questions About Carelon Behavioral Health
If you’re exploring your treatment options and how they might be covered through Carelon Behavioral Health insurance, it’s normal to have some ongoing concerns. For this reason, we’ve provided some answers to FAQs on the subject.
What Is Carelon Behavioral Health Also Known As?
Carelon Behavioral Health was once known as “Beacon Health Options.” They changed their name in 2023 but provide the same mental health services under the new brand. You might still see Beacon listed on older insurance materials or provider directories. But their role in managing mental health benefits has stayed largely the same.
Is Carelon Behavioral Health Part of Anthem?
Yes, Carelon Behavioral Health became part of Anthem, now known as “Elevance,” in January 2025.5 Carelon often manages the behavioral health benefits for the plans that are associated with Anthem, though coverage details still vary by plan.
What Mental Health Conditions Will Carelon Cover?
Carelon mental health benefits commonly apply to conditions like depression, anxiety, trauma-related concerns, and other challenges that impact daily functioning. Coverage can also extend to Carelon trauma treatment, autism spectrum disorder, eating disorders, and family issues when clinically appropriate.
Can Mission Connection Help With Behavioral Health Coverage?
Yes, we can help you verify and understand your benefits. Our team will work with you to understand how your benefits apply to therapy, treatment programs, and other care options. We can also help explain what your coverage looks like.
References
- Carelon Behavioral Health. (n.d.). Carelon Behavioral Health: Behavioral health services and solutions. https://www.carelonbehavioralhealth.com/
- Coleman, K. (2025, January 3). Third Party Administrator TPA Definition. https://www.associationhealthplans.com/glossary/tpa/
- National Association of Private Psychiatric Hospitals, & American Association for Partial Hospitalization. (1990). Definition of partial hospitalization. Psychiatric Hospitals, 21(2), 89–90. https://pubmed.ncbi.nlm.nih.gov/10106610/
- American Medical Association. (2023). Policy Finder. https://policysearch.ama-assn.org/policyfinder/detail/H-320.953?uri=%2FAMADoc%2FHOD.xml-0-2625.xml
- Anthem. (2025, March 25). Provider News. https://providernews.anthem.com/indiana/articles/anthem-will-delegate-care-management-to-carelon-health-inc-24645
