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Navigating Your Mental Health Insurance Benefits



by Miriam R Rieck

Lake Travis Counseling Connection


How To Navigate Your Mental Health Insurance Benefits


Navigating your mental health insurance benefits can be confusing, especially when you're in the middle of an acute episode. But knowing how to navigate your insurance and how to get the help you need can make all the difference in your recovery. Mental health insurance coverage is often processed differently than basic medical coverage. Here we'll help you understand how mental health insurance works and how to navigate the differences between mental and physical health coverage.


Familiarize Yourself with Your Plan

The first step is getting familiar with your plan. If you have a more comprehensive plan, this may involve contacting your insurance company directly If not, there are often resources online that can help you understand what's covered by your plan and what isn't. You can also talk to a doctor or therapist about what kinds of treatment options are covered by your plan and which ones aren't covered at all.


Once you've gathered some information about what's covered by your plan, it is time to decide what kind of care is best for you. In some cases, this might mean seeking out a therapist who accepts your insurance coverage. In other cases, it might mean seeing a psychiatrist or other medical professional who specializes in treating mental health conditions without requiring insurance coverage first (or at all) and are strictly direct or cash payments only.


Tips for Starting the Process of Understanding Your Mental Health Insurance Benefits
  • Do not wait until you need the care to look into your options.

If you have any indication that you could benefit from seeing a therapist or psychiatrist, then it's best to start looking into your options now. It is easy to get overwhelmed by all of the different plans and options out there, but if you know what type of coverage you need upfront, then it should be much easier when the time comes.

  • Find Out What Kind of Coverage You Have and READ THE FINE PRINT!

Your healthcare provider should be able to explain what kind of coverage they offer and who qualifies for the plan. Make sure that this information matches up with what your insurance company says about their coverage as well so that there is not any surprises later down the line. Understand how those services are delivered, including whether they're in-network or out-of-network providers and whether there is any cost for those services at all (for example, if you have to see a specialist). What is your copay? Do you have a deductible? How much is your deductible (we will cover the deductible a little later).

  • What is covered?

Mental health benefits cover both inpatient and outpatient care. Inpatient care means staying overnight at a hospital or other facility. Outpatient care means receiving treatment away from a hospital but still under medical supervision. You can receive mental health services through an HMO, PPO, or POS plan as well as an EPO plan. You should check with your insurer about what is covered by each type of plan.

  • Who is eligible?

As a general rule, plans will cover psychological counseling even if there has not been an official diagnosis made by another professional such as a doctor or psychiatrist. Mental health is a critical part of your overall well-being. If you have a family, they are typically under your health plan and should be covered the same way as the primary insured is.


Learn the Details of Your Plan

Insurance companies are required by law to cover mental health services, and they're required to provide certain types of coverage depending on what kind of plan you have. Insurance companies can also choose to "sell" or have a third party payer administer their plan. A provider that is in-network with a plan like Aetna, Cigna or BCBS MAY NOT be in-network with the third party payer and you may find out several sessions later that you are not covered and have a large bill to pay for. Mental health providers do not have to obtain prior authorization and many times are just as surprised as you are to find out that you are not covered.


Types of Insurance Coverage

We know it can be confusing to figure out how this works as well. So here is a quick breakdown of the types of insurance coverage.


If you have an HMO plan, your insurer will cover most of your mental health services without any cost-sharing (or copay). That means that the service is covered by your plan and does not require a copayment from you when you visit a provider. The exception is substance use disorder treatment. These services may require copayments depending on whether or not they are provided by an in-network provider.


If you have an EPO plan, some benefits may require copayment amounts that vary by service type-for example, if you go to see a psychologist in an in-network facility for individual therapy sessions, it may cost $15 per session; if you go for group therapy sessions at the same facility, it may cost $10 per session.


Deductibles: Insurance VS Direct Pay

Many times insurance companies charge a separate and higher deductible for mental health coverage as opposed to physical health coverage. In some cases, it may actually be cheaper for you to negotiate a direct pay rate as opposed to paying for a deductible. Make sure that you understand what options are available for going to out-of-network providers-these may be less expensive than in-network providers and may offer more flexible appointment times and locations and a substantial reduction in fees.


Here are some things to consider when trying to decide if you want to use insurance or go direct pay to the provider.

  1. if you are using insurance the provider is obligated under their in-network credentialling to report your diagnosis to the insurance company so that it becomes part of your available insurance record.

  2. Your mental health coverage is actually administered by a third-party payer, the insurance company is obligated to tel you this when asked and you are going to end up paying for the sessions in cash because the powder is considered out-of-network.

  3. If your provider charges an administrative fee for insurance clients.

  4. If your deductible is so high that you will be paying a deductible for the entire calendar year.

The system is complicated and filled with jargon, but there are ways to cut through the confusion and find the coverage that works best for you.


Even if you're not sure you need to use your mental health insurance benefits, it is important to know how they work. If you are ever in a situation where you need them, it will be much easier if you already understand the basics.


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