by Sarah Allen Benton, LMHC, and Denise Egan Stack, LMHC
This article was initially published in the Spring 2008 edition of the OCD Newsletter.
Each insurance company has its own system in place for obtaining mental health benefits and referral information. However, there are certain terms and procedures that are common to many, and they are listed below in hopes of helping you navigate the often complicated process of accessing your mental health benefits.
This information is offered as suggestion only. We have purposely excluded information on Medicaid and Medicare in this section, but it is forthcoming.
Look on the reverse side of your insurance card and locate the “mental health/substance abuse” phone number. If this number is not on your insurance card, then look for the “customer service” phone number. When you call either of these phone numbers, there are two main pieces of information that you should obtain:
- Benefit information
- Mental health provider and/or facility referral names and contact information
If your medical benefits are issued through one company, do not assume that your mental health benefits are administered through the same company. For example: some Blue Cross/Blue Shield plans have mental health benefits contracted through Magellan a completely different company.
Before calling your insurance company, determine what level of care you will need to appropriately treat your mental health condition. You may obtain this information from a current mental health provider, primary care doctor recommendation, research on your condition, and/or by consulting with a mental health professional at your insurance company. The terminology for levels of care may differ between insurance companies; therefore we have listed a brief description of the most common levels of care ranked in order from less to most intensive:
Outpatient individual therapy: Patients see a therapist for individual sessions as frequently as determined by an initial psychological assessment, generally one or two times a week for 45-50 minutes.
Intensive outpatient: Patients attend several groups, and one individual session, per day several days per week.
Partial hospitalization: This level of care is sometimes called “day treatment.” Patients attend treatment during the day at a mental health treatment facility or hospital, usually from 9am – 5pm, up to five days a week.
Residential: Patients are treated while residing voluntarily in an unlocked mental health treatment facility or hospital unit.
Inpatient: This is the highest level of care for a mental health condition. Treatment is provided on a locked unit in a psychiatric hospital on a voluntary or sometimes involuntary basis. Patients are admitted into this level of care if they are suicidal, homicidal, or are unable to care for themselves due to their psychiatric condition. The goals of inpatient treatment are to stabilize the patient which generally takes several days to a week, and then transition the patient to a lower level of care.
When calling your insurance company to obtain benefit information, follow the telephone prompts for “members” and then “obtaining benefit information.” Once you reach a live service representative, you will be asked to answer a series of questions in order to identify yourself (social security number member, ID#, date of birth, cardholder’s address). After you have identified yourself there are several questions that you are going to want to ask the representative:
What are my benefits for the level of care that I need (see Step 2 list)?
Specifically, you will want to ask what your “in-network” benefits and “out-of-network” benefits are. It is generally more cost effective to utilize in-network benefits, and most HMO plans do not offer out-of-network benefits. In order to utilize your in-network benefits, you must choose a provider or treatment facility that is participating in the insurance plan. These names can be obtained through your insurance company and this process is described in Step 4.
If the provider you wish to see is not covered by your insurance company’s network, then ask the insurance company if they will make a “single case agreement” with the out-of-network provider. The most effective way to do this is by making the case that the provider offers an expertise that is not offered in their network of providers. While we know of this happening on several occasions, it does not happen often.
The benefit description will contain several terms that are important to understand.
You will need to know the number of therapy sessions or days of treatment per calendar year that your plan covers. You should ask if there is the option for “parity” and if so, for what mental health conditions. Parity would allow your mental health provider to determine if you have a biological condition that requires more sessions or a longer hospital stay than your plan provides. If you have parity in your plan, then your insurance company will allow for more, or even unlimited, sessions/days. Most insurance companies that we have worked with consider OCD a biological illness and therefore parity applies.
What is the Deductible
The amount of money that you have to pay out of pocket before your insurance company begins to pay.
What is the Co-payment
The flat fee that you must pay each time you have a session (generally it is between $5-20). Your insurance company pays for the remainder of the charges.
Is authorization needed to start treatment at the level of care I think I need?
You may have certain insurance benefits in your policy, but that does not mean that the insurance company will let you use them at any given time. If authorization is needed then it is important to ask what phone number to call to obtain authorization, and how soon prior to the start of treatment you should call. You will need this information for Step 5.
Once you have obtained benefit information, you will need to find out how to obtain a referral list of mental health providers and/or treatment facilities.
The criteria that you should have in mind during this process are:
- What type of mental health provider are you looking for?
- Are you looking for a psychologist licensed clinical social worker, licensed mental health counselor, or psychiatrist? See credentialing information below for more information on different types of mental health providers.
- What type of treatment facility you are looking for (if any)?
- What specialization would you prefer the provider have experience with (OCD substance abuse, eating disorders, anxiety disorders)? If OCD is not a choice consider working with someone who specializes in anxiety disorders.
- What gender do you prefer your provider be?
- What zip code you would like your provider or treatment facility to be located in and how many miles you are willing to travel to get there?
There are generally three ways to acquire this referral list:
- Ask the insurance representative to verbally list the names, addresses, and phone numbers of providers and/or treatment facilities that fit your criteria.
- Ask for the company website address in order to print out a list of providers/treatment facilities yourself. If you choose to do so we suggest that you initially access the website while you are on the phone with the insurance representative, so that he/she can guide you through the site.
- Some insurance representatives will conduct the website search for you, and then email or fax the list to you.
Once you have received benefit information and picked a treatment provider/treatment facility, you may need to call your insurance company to get authorization to use your benefits. You should know whether or not you need authorization based on the information you gathered when you initially called your insurance company to obtain benefit information (see Step 3 number 2). For example, if you have severe OCD have been accepted into the MGH/McLean OCD Institute for residential treatment, and have residential benefits under your insurance policy but need authorization to start your care, this is the time to get authorization. Sometimes your insurance company will give you the subscriber authorization, and other times they want to hear from your treatment provider/treatment facility at the time of admission.
If you are denied authorization to use your benefits, you, as a subscriber to any type of insurance, have a right to appeal the decision. You should ask, “What is the appeal process?” Generally, there are several levels of appeal to pursue which may include you or your treatment provider writing letters or making phone calls on your behalf. If you are going to pursue an appeal, it is important to get information about timelines for appeal. Also, be sure to document content of all calls (date/time) and the names of the people with whom you have spoken. Don’t forget, the human resources department where you work may provide assistance to you during an appeal process.
If you have exhausted all levels of appeal through your insurance company and you are still denied authorization, there may another step to take depending upon the state in which you live. Contact your state insurance commission to determine if they might be of help to you. According to: www.patientrights.com, state insurance commissions “are the state government bodies responsible for regulating insurers’ and health plans’ activities. Most have consumer complaint processes.” You may appeal to your state insurance commission, which may issue an independent ruling that your insurance company is required to follow. If all else fails and you consider suing your insurance company for insurance coverage, we recommend you seek legal representation.
Mental Health Referral Information Form
Insurance Contact Information:
Mental health referral phone number ________________________________________
Customer Service phone number(s) _________________________________________
Substance Abuse referral phone number:_____________________________________
Number of sessions/days:_________________________________________________
Number of sessions/days:_________________________________________________
Instructions once provider selected
Authorization needed (when and at what phone#?):__________________________
Does Primary Care Provider (PCP) need to be notified?:________________________
Other instructions ____________________________________________________
Mental Health Provider/Treatment Facility Referral Information:
Gender preference ____________
Zip Code ____________________
Maximum mile radius from Zip Code: 1 5 10 20 30 40 50
Type of provider(s)/facility requested ________________________________________
Specialization(s) preferred: _____________________________________________________
Provider/treatment facility list website address(es):___________________________________
Glossary of Insurance Terms
Benefit Package. Services covered by a health insurance plan and the financial terms of such coverage. These include cost limitation on the amounts of services, and annual or lifetime spending limits.
Claim. A request by an individual (or his or her provider) to that individual’s insurance company to pay for services obtained from a health care professional.
Consolidated Omnibus Budget Reconciliation Act (COBRA). An act that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment. COBRA imposes different restrictions on individuals who leave their jobs voluntarily versus involuntarily.
Co-payment. Another way of sharing medical costs. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The insurance company pays the rest.
Deductible. The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.
Group-model Health Maintenance Organization (HMO). A health care model involving contracts with physicians organized as a partnership professional corporation or other association. The health plan compensates the medical group for contracted services at a negotiated rate and that group is responsible for compensating its physicians, and contracting with hospitals for care of their patients.
Health Maintenance Organization (HMO). A type of managed care plan that acts as both insurer and provider of a comprehensive set of health care services to an enrolled population. Services are furnished through a network of providers.
Indemnity plan. Indemnity insurance plans are an alternative to managed care plans. These plans charge consumers a set amount for coverage and reimburse (fully or partially) consumers for most medical services.
Managed Care. An organized system for delivering comprehensive mental health services that allows the managed care entity to determine what services will be provided to an individual in return for a prearranged financial payment. Generally, managed care controls health care costs and discourages unnecessary hospitalization and overuse of specialists, and the health plan operates under contract to a payer.
Mental Health Parity (Act). Mental health parity refers to providing the same insurance coverage for mental health treatment as that offered for medical and surgical treatments. The Mental Health Parity Act was passed in 1996, and established parity in lifetime benefit limits and annual limits.
Network. The system of participating providers and institutions in a managed care plan.
Point-of-service plan (POS). A modified managed care plan under which members do not have to choose how to receive services until they need them. Members receive coverage at a reduced level if they choose to use a non-network provider.
Preferred Provider Organization (PPO). A health plan in which consumers may use any health care provider on a fee-for-service basis. Consumers will be charged more for visiting providers outside of the PPO network than for visiting providers in the network (American Association of Preferred Provider Organizations).
Professional Mental Health Credentials
Ph.D. Doctor of philosophy. This academic degree is earned in four to seven years. Many psychologists therapists counselors and coaches hold a doctorate of philosophy. A Ph.D in psychology teaches theory, as well as statistics and data gathering (APA).
Psy.D. Doctor of psychology. The Psy.D. is a terminal degree, like a Ph.D. however, the Psy.D. focuses on therapy and counseling rather than research. The degree was developed in the late 1960s to address the need for practitioners. In the last 30 years, the Psy.D. has become increasingly popular (APA).
M.D. Psychiatrists are medical doctors who, after completing medical school, receive an additional four years of clinical training in mental health specialties. Psychiatrists treat emotional and mental disorders and are licensed to prescribe medication. These professionals may treat psychiatric disorders with therapy in conjunction with psychotropic medications (APA).
L.C.S.W (or A.C.S.W. L.C.S. L.I.C.S.W. C.S.W.) The licensed clinical social worker has a graduate academic degree, has completed supervised clinical work experience, and has passed a national or state-certified licensing exam. This advanced practitioner holds a license that allows him or her to receive health-care insurance reimbursements (National Association of Social Workers).
L.M.F.T (or M.F.C.C.) The licensed marriage and family therapist has a graduate academic degree (a two to three year master’s degree or a three to five year doctoral degree), clinical work experience, and has passed a state-certified licensing exam. Most states offer this license. Along with the two to three year full-time masters programs with a practicum and internship ,LMFTs are required to complete 1,000 hours of individual or family therapy, with 100 hours of supervision. This can take one to three years. This license is not Medicare reimbursable (American Association of Marriage and Family Therapists).
L.M.H.C. The licensed mental health counselor has a graduate degree (two to three year master’s degree), clinical work experience pre and post master’s degree, and has passed a state-certified licensing examination. Along with the master’s degree practicum and internship, LMHC’s are required post-master’s degree to complete 3,360 hours of field experience, 960 hours of clinical experience, and a minimum of 130 hours of supervision. This advanced practitioner holds a license that allows for mental health insurance reimbursements. This license is not Medicare reimbursable.
L.P.C (or L.C.P.C. D.A.C. M.F.C.C.) The licensed professional counselor licensing qualifications are granted to those who have advanced training a graduate academic degree, clinical work experience, and have passed a state-certified licensing examination. This degree is not Medicare reimbursable (American Counseling Association).
Source www.psychologytoday.com 5/7/2007