No. 26; Updated March 2011
Insurance benefits for mental health services have changed a lot in recent years. These changes are consistent with the nationwide trend to control the expense of health care. It is important to understand your mental health care coverage so that you can be an active advocate for your child's needs within the guidelines of your particular plan. Here are some useful questions to ask when evaluating the mental health benefits of an insurance plan or HMO:
- Do I have to get a referral from my child's primary care physician or employee assistance program to receive mental health services?
- Is there a "preferred list of providers" or "network" that you must see? Are child psychiatrists included? What happens if I want my child to see someone outside the network?
- Is there an annual deductible that I pay before the plan pays? What will I actually pay for services? What services are paid for by the plan: office visits, medication, respite care, day hospital, inpatient?
- Are there limits on the number of visits? Will my provider have to send reports to the managed care company?
- What can I do if I am unhappy with either the provider of the care or the recommendations of the "utilization review" process?
- What hospitals can be used under the plan?
- Does the plan exclude certain diagnoses or pre-existing conditions?
- Is there a "lifetime dollar limit" or an "annual limit" for mental health coverage, and what is it?
- Does the plan have a track record in your area?
The following section explains terms and procedures commonly used in health plan. Managed care refers to the process of someone reviewing and monitoring the need for and use of services. Your insurance company may do its own review and monitoring or may hire a "managed care company" to do the reviewing. The actual review of care is commonly known as "utilization review" and is done by professionals, mostly social workers and nurses, known as "utilization reviewers" or "case managers." The child psychiatrist treating your child may have to discuss the treatment with a reviewer in order for the care to be authorized and paid for by your insurance. The reviewers are trained to use the guidelines developed by your health care plan. A review by a child and adolescent psychiatrist reviewer usually must be specially requested.
The review process often takes place over the telephone. Written treatment plans may also be required. Some plans may require that the entire medical record be copied and sent for review. Reviewers usually authorize payment for a limited number of outpatient sessions or a few days of inpatient care. In order for additional treatment to be authorized, the psychiatrist must call the reviewer back to discuss the child's progress and existing problems. Managed care emphasizes short term treatment with a focus on changing specific behaviors.
Preferred providers are groups of doctors, social workers, or psychologists which your insurer has agreed to pay. If you choose to see doctors outside of this list, (out of network caregivers), your insurer may not pay for the services. You will still be responsible for the bill. Similarly, care given in hospitals designated as "in network" is paid for by your insurance, while care given in hospitals "out of network" is usually not paid by your insurance and becomes your responsibility. Even when using preferred providers and in network hospitals, utilization reviewers still closely monitor treatment.
Another change is the variety of services and diagnosis paid for by different plans. In the past, only inpatient care and outpatient care was covered by insurance. Now, depending upon your particular plan, other services such as day hospital, home-based care, and respite care may also be covered. These lower cost services may offer advantages to inpatient hospitalization.
A limiting feature of some mental health care plans is a low lifetime maximum or a low annual dollar amount that can be used for mental health care. (i.e. Once this amount is used, plan coverage ends.) You, as parent or guardian, are responsible for paying the non-covered bill. If your child/adolescent needs continued care, you may need to seek help from your state public mental health system. This usually means changing doctors which may disrupt your child's care.
It is important to understand as much as possible about your particular insurance plan. Understanding your coverage will put you in a better position to help your child. Sometimes you may need to advocate for services that are not a part of your plan, but which you and your child's psychiatrist feel are necessary. Advocacy groups may provide you with important information about local services. The support of other parents is also useful and important when engaged in advocacy efforts.