Insurance Benefits

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What do I need to know about my insurance benefits?

Dealing with insurance plans can be challenging, 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. You should have received a copy of your insurance policy when you enrolled in the program, whether at work or independently. If you did not receive a copy of the policy or have lost yours, you can call your insurance company and ask for another one to be sent to you.

Even if you have a copy of the plan, it is always helpful to speak to someone else and clarify questions. This way you can identify any possible points of confusion before you receive a bill. You should have a number on your card or on the website that will tell you whom to contact.

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?

Many insurance companies, especially Health Maintenance Organizations (HMOs) require referrals from a primary care physician to visit any specialist, including mental health professionals. If you do not receive a referral before visiting a mental health professional, your insurance company may deny your claims. If you think you require a referral, you should always get it in advance.

2)   Do I need any pre-approval from the insurance company before I see a mental health professional?

referral is an authorization from a doctor saying that the treatment is medically necessary;pre-approval or pre-authorization­ requires that your insurance company agrees to make the payment. You should call your insurance company to see if you need pre-approval, but you should also keep other questions in mind-how many visits are you approved for? Do you need a new approval for each visit? If you are going to be hospitalized or in inpatient care, how many days are you allowed to stay?

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?

If you need an "in network" provider, you can usually find a directory online or ask your primary care physician to help pick someone out. 

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?

"In network" providers are almost always cheaper than "out of network" providers, although whether you want to save money or visit a doctor you prefer is a choice you will have to make. Bear in mind that your insurance company may not always have a flat difference. For some companies, seeing an "in network" provider may cost you a $20 co-pay, and an "out of network" provider will cost you $30; in others, "in network" may cost you $20 and an "out of network" may cost you 20% - which could be significantly higher than $30.

5)   Are there dollar limits, visit limits or other coverage limits 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?

It is not uncommon, based on your state and your plan, to have limits on psychiatric visits or medication management visits. Your plan may limit you to something like 25 sessions with a psychiatrist each year, up to 7 days of inpatient treatment a year, and 12 medication management visits a year. If you exceed these services, you will have to pay out of pocket.

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?

Insurance companies often have the option to not include certain diagnoses in all policies. If you applied with your condition as a pre-existing condition, they may not cover anything related to that. Your insurance company will provide you with a list of covered and uncovered diagnoses.. 

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?

Not all health insurance plans offer a prescription benefit plan in addition to a treatment plan. Even if you have a prescription plan, not all medications are covered. Many prescription plans have "formularies" that determine how much you pay for different classes or brands of drugs.  Covered medications fall into three categories:

  • Generic: These drugs are copies of brand-name drugs that have been on the market for a number of years and are often offered at very cheap prices.
  • Preferred: These drugs are name brand but are available to you at a price below the retail price.
  • Non-Preferred: These drugs are name brand but are not offered at a very large discount.

Insurance companies regularly update their formularies to classify drugs under certain payment categories. It's best to ask your doctor to help you find out what payment category your drug is in before you go to the pharmacy to avoid an unpleasant surprise when the bill arrives.

However, many prescription medications for mental health conditions are very expensive and even with health insurance, you can find yourself paying a lot for a prescription.

Mail Order Pharmacy - Some insurance plans will allow you to order a three- month supply of maintenance drugs through the mail for a reduced, standard price. 

Seek Outside Assistance - Go here to find out other ways to help pay for your prescription medication. 

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.

If you receive health insurance through your employer, you may be able to go to your Human Resources department. If your company is large, you may have a dedicated Benefits Specialist who will be able to help you navigate health care. If you work for a smaller business, you will want to talk to the person who arranged the health care. They may not be able to help and their knowledge may be administrative, but they may help put you in touch with an advocate who can put you on the right track. You may be hesitant to admit to your employer that you need help with a mental health condition, but it is not legal for your employer to fire you over a disability.

If you have private insurance, you can contact your state Insurance Department ( or state Insurance Commissioner's office (  (their consumer hotline may be the most helpful) for help in understanding your insurance policy. They can also help you find out 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 can assist you in dealing with your insurance company if you are having a problem.

Other Resources

The Center for Consumer Health Choices of Consumers Union has prepared a helpful guidebook "A Consumer Guide to Handling Disputes with your Employer or Private Health Plan". Section 1 "Know your Coverage" and the"Checklist for Diagnosing your Coverage" 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.

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