Mental Health Insurance: are you covered?

As you begin to receive therapy, it is more important than ever to be informed about your health insurance plan. You don't want to find out too late that your coverage is lacking in certain areas. Unfortunately, since insurance policies are complicated, most people do not fully understand their coverage.

You should fully understand your behavioral health coverage to ensure you and your family are adequately covered. When speaking with your employer or an insurance agent, the following information may enable you to discuss these very important issues in an informed way.

The time to figure out if you have adequate insurance is before you actually require the insurance. Understanding the type and scope of your behavioral health coverage is only the first step. You should also demand adequate coverage from those responsible for your well-being. Only then can you be assured of your own behavioral health and the health of your loved ones.

• Fact #1: Studies have shown that behavioral health care can improve a person's overall health while reducing medical over-utilization by up to 75%.

• Fact #2: Employers who provide an appropriate level of behavioral health coverage have better functioning employees.

• Fact #3: Making outpatient behavioral health coverage readily available reduces overall health care expenditures.

Questions to ask your Insurance Agent or Employer

1. If you need behavioral health care, can you choose your own psychiatrist or therapist?

2. Does your insurance plan allow you to choose a provider recommended by your family doctor?  What happens if you don't have a primary care physician?

3. If you want to see a particular therapist, is that option available to you or will you be forced to see the provider chosen by the insurance company? Do you have to be referred to a therapist by a general practitioner?

4. Will you be able to see your therapist on a regular basis or will you be seen by a different therapist at each visit?  If you decide that you need to see a therapist, can you go directly to the therapist's office or do you have to obtain approval from your general practitioner or some other gatekeeper?

5. Will your company allow your therapist to join the insurance group's list of providers?

6. Are you limited to a specific number of therapy sessions per year or per problem (such as 5 sessions) or can you receive as much counseling as the therapist deems necessary? Is there a cap or limit on the amount of therapeutic assistance you can receive?

7. Who determines the treatment decisions; your insurance company or your therapist?

8. What if you need more help than your plan allows?  If you have an Employee Assistance Program (EAP) where you work, what happens when you have used up your allotted number of counseling sessions?

9. Who in your family is covered by your insurance plan?

10. If you are having marital or other relationship problems, can you receive treatment to help relieve some pressure or stress resulting from that strained relationship?

11. Is drug detoxification covered? If you need help to stop drinking or to stop taking a drug to which you may  be addicted will this be covered by your insurance? Is coverage provided on an inpatient basis? Are you eligible for an inpatient drug rehabilitation program?

12. Are you covered for depression and anxiety even though you don't need to be hospitalized?

13. Do you need to have a specific acceptable diagnosis in order to obtain insurance reimbursement? Are only certain severe diagnoses approved by your insurance carrier?

14. Are psychotropic (prescribed for your behavioral health) medications covered?

15. Does your insurance cover medication needed for mental disorders (which you may require on a long-term basis)? Are you covered only for generic drugs or particular medications even if your doctor insists on specific brand name prescriptions?

16. Do you have to pay part of the cost yourself (a co-payment)? What is your deductible (the amount you have to pay before your insurance starts to pay)?  What are your out-of pockets expenses before your insurance begins to pay your bills?

17. Are you reimbursed directly or is the therapist paid by the insurance company? Find out who pays, who is reimbursed, and how long this process takes.

18. Is psychological testing covered? Your therapist may feel that testing is required. If so, will this be covered or will you have to pay for it yourself?

19. Is a second opinion covered by your insurance? If you are not satisfied with your therapist's diagnosis or treatment plan, can you see another therapist to obtain consultation?

20. What happens if you miss work due to a mental illness or a detoxification program? Is your workplace and insurance plan supportive of your behavioral health? Is access to help made easy? Will your employer penalize you for seeking mental health treatment?

21. Is group counseling covered? This may be productive and cost-effective way for you to obtain therapy, but is it covered by your plan?

Source: 1-800-Therapist
Review Date: April 25, 2010
Reviewed by: Barb Hansen BScMLT