Dealing With Insurance Providers

Mental health services can be expensive. While insurance can help offset the cost, it can also be a source of frustration and confusion. To determine which mental health services are available to you under your insurance coverage and to help prevent complications, delays and/or unexpected costs, it is crucial that you read your insurance policy or handbook carefully and/or speak to an insurance representative prior to contacting a potential treatment provider. Check your insurance card for a toll free telephone number that will put you in contact with an insurance representative who can answer your questions.

There are typically three types of insurance coverage — traditional, preferred provider (PPO), and managed care (HMO).

Traditional Plan: A traditional plan gives you the most options. You can see a licensed treatment provider of your choice, pay the fee and submit the claim for reimbursement. The percentage of the fee you are reimbursed may range from 50% – 100% depending on your policy. Some policies require that you pay a deductible prior to being eligible for reimbursement.

Managed Care Plan (HMO): A managed care plan requires you to see a treatment provider who is contracted with your insurance company (referred to as a “in-network” provider). With some policies you may need a referral from your primary care physician to initiate treatment. You pay a co-pay ranging from five to twenty-five dollars at the time of service. The treatment provider submits your claim to the insurance company and is paid the balance of the fee directly from the insurance company. Under the HMO plan, initial and ongoing sessions are subject to pre-authorization and review by your insurance provider.

Preferred Provider Plan (PPO): A preferred provider plan allows you to see either a contracted (“in-network”) treatment provider at the cost of a co-pay or a licensed treatment provider of your choice. Under the PPO plan, if you choose to see a treatment provider that is out of network, the fee reimbursement is typically lower then it would be with the traditional plan. In speaking to your insurance representative, it may be helpful to ask the following questions (it is crucial that you document all conversations, dates and names of contact personnel):

• All plans: What type of policy do I have? Traditional? Preferred Provider (PPO)? Managed Care (HMO)?
• All plans: Are mental health services covered?
• Traditional plans: What is the percentage that I will be reimbursed?
• Traditional plans: Do I have to pay a deductible prior to receiving reimbursement? If so how much is my deductible (e.g., $500, $1000, etc.)
• HMO plan – Do I have to pay a co-payment? If so, how much is my co-payment?
• All plans: Are both outpatient and inpatient treatment covered?
• All plans: Do I need a referral from my primary doctor? If so, what is the best procedure for obtaining one?
• All plans: Do I have to start with outpatient treatment prior to accessing inpatient treatment?
• Traditional plan: If I receive individual outpatient treatment, what credentials does the treatment provider need in order for me to receive reimbursement for the treatment?
• Traditional plan: Is there a limit on how high the professional’s charge may be (e.g., $120, $250, etc. per session), what is the maximum fee for which I will be reimbursed?
• All plans: What is the total amount the insurance will pay on a yearly or a per contract basis for mental health services (e.g., $5000, $10,000, etc.).
• All plans: If the parents or family members of the identified client need to be seen separately, do specific rules apply? What are those rules? How does the treatment provider need to document those sessions in order for me to be reimbursed?
• HMO type: Are there “out of network” benefits (PPO option) available? How do I obtain those “out of network” benefits? How do those “out of network” benefits differ from “in network” coverage? What is the percentage of reimbursement? Is there a deductible?
• All Plans: If my child is covered by more than one insurance policy, do special rules apply? What are they? What are the steps I need to take in processing the claim and ensuring reimbursement?
• All Plans: Is there anything else I need to know to ensure that I can obtain the type of treatment I am seeking, that my claims will are processed expediently and properly and that I receive the correct reimbursement?
• All plans: What are the steps I need to following in obtaining the services that I am seeking?

If you have an HMO policy, ask your insurance representative for a list of “in-network” providers. When selecting a treatment provider from a list of unknown names, it is strongly recommended that you follow the recommendation outline in the selecting a psychotherapist section outlined on this week page prior to scheduling your first appointment.

If you are on public assistance and you have Medicaid as your insurance, follow the strategies outlined above for an HMO policy.