If you are confused by your insurance benefits, you are not alone. Hopefully, this page will give you the tools you need to sort out what sort of mental health coverage you have. It may even give you some insight into why you have been confused about your insurance coverage.

  Insurance policies usually divide mental health services into three areas. They are out-patient, in-patient, and drug and substance abuse treatment. Your policy will probably stipulate what the insurance company will cover in each of these areas. Most policies consider out-patient mental health to be individual therapy, not couples therapy or group therapy. Some policies will cover couples therapy or group therapy. Every visit with each out-patient mental health provider you have counts toward your out-patient mental health benefits maximum. In other words, if you are in weekly therapy and see a psychiatrist periodically, the psychiatrist visits will be considered sessions on par with the therapy unless the psychiatrist uses a medical procedure code rather than a psychiatric procedure code (Procedure codes are 5-digit codes that say what sort of service you received. An out-patient therapy session that is more or less 45 minutes long is coded 90806.). Typically, your insurance company will allow for one 45-minute session weekly.

  Insurance companies prefer you use providers who are part of their network. This is referred to as in-network providers. They cover services from in-network providers at a different rate than out-of-network providers. You will need to know if your therapist (and psychiatrist, if you use one) is in or out of network. If you have an HMO policy, you must use in-network providers. A therapist who is a PPO provider is not necessarily an HMO provider, and vice versa. Find out how your carrier covers therapy provided by in-network and out-of-network providers.

  Your policy is with a particular company, but your mental health benefits may be farmed out to another insurance company. For instance, you may have BlueCross BlueShield insurance for physical health, but (often unbeknownst to the policy holder) the mental health portion is handed over to Magellan (for instance). It could be that Magellan is only the administrator, and the benefits are under BCBS. It could be that Magellan is the carrier for mental health services. In that case, what matters is Magellan’s network of providers and Magellan’s rates of reimbursement. Again, this will not necessarily be spelled out on your insurance card. Talk to your insurance company to find out who is the carrier for mental health benefits.

  Most insurance policies have a deductible. This is the amount you have to pay out of pocket before the insurance benefits kick in. Usually, but not always, sessions that go toward meeting your deductible also count toward your annual (and lifetime) maximum number of sessions. Usually, but not always, medical and mental health services are rolled into one deductible. Check out how your deductible works. Once you have met your deductible, the insurance carrier will pick up a portion of your therapy costs. In some few cases, the insurance carrier covers the whole fee. In most cases, the client is responsible for a portion of the fee. The client portion may be in the form of a co-pay, a co-insurance, or both. A co-pay is a set amount of money for an office visit. A co-insurance is a percentage of the fee. Find out what your co-pay and co-insurance are so you will know what each session will cost you once you meet your deductible.

  Most insurance companies have a maximum number of sessions allowed each policy year, and a lifetime number (or dollar amount) allowed. It is important that you know when your policy year begins (it isn’t always in January) and what the yearly and lifetime maximums are. Some insurance policies allow a person to swap in-patient benefits for out-patient benefits once the person has run out of allowed out-patient sessions—providing the insurance company considers it a medical necessity to do so.

  If you have an HMO, you must call your insurance carrier to certify your initial sessions or your carrier will not pay for those sessions. Some PPO and POS policies also require you to pre-certify sessions. Your insurance card will not tell you whether or not this is the case. You will need to call your carrier (or talk with your Human Resources Department) to find out whether or not you need to pre-certify. Some PPO or POS policies will certify only a handful of sessions at a time, regardless of what the annual maximum is. After those sessions are used up, the therapist has to certify more sessions. There is no guarantee that the carrier will agree to more sessions—even though the annual maximum hasn’t been met. Unfortunately, this can create anxiety for both the client and the therapist, as they are dealing with uncertainty regarding how long they can work together, and who will pay for sessions.

  While many therapists track the number of sessions clients have to know when each client is reaching the annual (or lifetime) maximum, you should be tracking this as well. If the therapist miscalculates, or doesn’t track, you will become responsible for the full fee for all sessions not covered by your insurance company.

  Pre-existing conditions refer to documented mental health conditions you had prior to joining this policy. Most insurance policies offered by large employers don’t rule out coverage for pre-existing conditions. If your policy does exclude pre-existing mental health conditions, check and see whether not having received mental health services for a stipulated amount of time allows coverage for mental health services now. If you are subject to a pre-existing condition clause for mental health benefits, your carrier will not cover any of the cost of sessions.

  Once you begin therapy, you are responsible for all of the therapist’s allowed fee not reimbursed by your carrier for any reason other than untimely filing of claim by an in-network therapist. “Allowed fee” means the amount the therapist is allowed bill for services under his/her contract with the insurance company. Yours (or your therapist’s) ignorance of your benefit coverage still leaves your liable for everything not covered by the insurance carrier. If your therapist is out-of-network, there is no contractual arrangement between the therapist and insurer determining the fee, and the therapist is legally obligated to charge his or her full (uncapped) fee.

  After your therapist files a claim, your carrier will send both you and the therapist an Explanation of Benefits (EOB). This (usually hard for the lay person to decipher) print-out lists dates of services, how much the therapist billed and how much the insurance company allows, what portion of this is the patient’s responsibility, and what the insurance company is paying the therapist. If anything other than “patient responsibility” is not paid to the therapist, the EOB will give the reason for non-payment. Any amount of the fee not covered by the carrier will most likely be transferred to you. If you are having trouble reading your EOB, you can ask you therapist to translate (he gets the same print out) or call Member Services of you insurance company.

  In summary, call your insurance carrier and ask:
  • What is my deductible and
  -   for in-network providers
  -   for out-of-network providers
  -   is my medical and mental health deductible combined?
  -   how much of my deductible has been met already?

  • Do I need to pre-certify mental health sessions?
  -   if yes, can you give me a code for pre-certification?

  • What is the maximum number of sessions I’m allowed a year?
  • What is the maximum lifetime mental health coverage I’m allowed?
  • Do I have a co-pay and if so, what is it?
  • Do I have co-insurance and, if so, what is it?
  • Do I have a pre-existing condition concerning mental health coverage and, if      so, what is the diagnosis code? When does the pre-existing clause end?

  • Is my therapist an in-network provider?
Please note that some insurance carriers do not list the therapists at CoCreate under their individual names but under CoCreate.