Factsheet: What do I need to know about my insurance benefits when seeking treatment?
Dealing with insurance companies can be very frustrating, especially when you are already stressed and worried about mental health issues you or a loved one are experiencing. For this reason, it is best to understand your benefits before you need to use them, if at all possible. The following are steps you can take to make sure you understand your benefits so that you can do whatever is within your control to have your treatment covered.
Reviewing Your Insurance Policy
The first thing to find out is what mental health benefits your insurance policy offers. Review your insurance policy so that you are clear about whether your policy includes coverage for mental health services, types of services that are covered and the amount paid for these services, and any steps you must take to have treatment covered. The following are some questions you will want to ask your insurance company, if possible, before starting treatment:
1) Do I need a referral from my primary care physician to a mental health professional?
2) Do I need any pre-approval from the insurance company before I see a mental health professional?
3) Do I need to see a mental health professional who is on a list provided by my insurance company (in a "network") or am I free to choose any qualified professional?
4) Does the amount paid by my insurance company depend on whether I see a professional who is "in their network or preferred provider list" or "outside the network"? If so, what is the difference in the amount paid or percent reimbursement for "in network" vs. "out of network" providers?
5) What if any dollar limits, visit limits or other coverage limits are there for my mental health benefits? Is there a difference in what is paid for outpatient vs. inpatient treatment? If so, what are my benefits for each of these?
6) Is there a specific list of diagnoses for which services are covered? If so, is my diagnosis one of those covered by my policy?
7) What prescription benefit does my policy offer? What are the co-pays for medications? Are there different levels of prescription coverage depending on the specific medication? Do co-payments vary depending on whether the medication is generic or name brand?
Seeking Help in Understanding Your Policy
If you have trouble understanding the policy, see if someone from your doctor's office, your employer, or a trusted friend, can help explain the information. Your company's Human Resources department is there to help you. If necessary, contact your state Insurance Department http://www.naic.org/state_web_map.htm or state Insurance Commissioner's office http://www.naic.org/documents/consumer_hipaareps.pdf (their consumer hotline may be the most helpful) for help in understanding your insurance policy and whether your company benefits follow the state mental health parity laws (laws that guarantee equal coverage for mental health conditions as for other health conditions), and whether they can help you deal with your insurance company if you are having a problem.
Other Resources
The Center for Consumer Health Choices, Consumers Union has prepared a helpful guidebook "A Consumer Guide to Handling Disputes with your Employer or Private Health Plan" http://www.kff.org/consumerguide/7350.cfm. Section 1 "Know your Coverage" and the "Checklist for Diagnosing your Coverage" http://www.kff.org/consumerguide/05-checklist.cfm may be particularly useful. You can complete the checklist once you have spoken with your insurance company. Once completed, the checklist can serve as a handy reference should you need services in the future.
For More Information:
For help finding treatment, support groups, medication information, help paying for your medications, your local Mental Health America affiliate, and other mental health-related services in your community, please click here to access our Frequently Asked Questions and Answers. If you or someone you know is in crisis now, seek help immediately. Call 1-800-273-TALK (8255) to reach a 24 hour crisis center or dial 911 for immediate assistance.
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