If you are looking for help or support, getting started with mental health therapy, for whatever situation you're dealing with, if they're concerned about financial costs or investment, or how to start therapy.
 |
| Health |
mantel health
One of the main costs of therapy is financial. This is where insurance can potentially help out. So real quick, before we dig into this, I need to just point out that I am not an insurance expert.
The best person to talk about when it comes to seeing how your insurance can potentially cover the financial aspects of paying for therapy is your insurance provider themselves.
And that's because each person's insurance provider, and plan under that insurance provider, may look a little bit different because it's catered to you or your family's needs.
In the United States of America, we do have what's called mental health parity.
Insurance providers must provide equal or similar coverage for benefits, of mental health, behavioral, or substance use conditions, as they do for other health conditions.
So just a quick note that equal coverage does not equal good coverage. It just means comparable or similar.
In-network coverage is typically the easiest to understand because it's the most widely used use of your insurance coverage for health services.
So what this means is that when somebody is considered in-network with your insurance plan, they have a written contract with the insurance provider,
that they will accept the rate that the insurance will pay them in exchange for their members being able to access services with that provider.
So that means, say, for example, you have ABC insurance. Yes, I'm making up insurance, because insurance plans are all different, and I don't want you to mistake the example for an actual insurance provider.
ABC insurance, you go to their website, or you go to a provider's website, and you look and see, do they accept ABC insurance as direct payment?
If they do, that means that they are in-network. And so you would just follow whatever coverage plan your insurance says that they cover for in-network services.
So this may mean meeting the deductible. May mean paying a copay. It may mean something completely different, check with your insurance provider directly.
Now, many mental health therapists actually prefer to work on what's called an out-of-network basis.
So out-of-network means that they are still licensed, able to provide the services that your insurance may or may not cover.
But it would be under what's called an out-of-network coverage benefit. That means that that provider does not have a contract with that insurance.
So you would pay for the services upfront, and then seek reimbursement from your insurance provider out of your out-of-network coverage benefits.
If you have the letters PPO or POS on your insurance card, you more likely than not have out-of-network benefits.
If you're not sure if you have out-of-network coverage, or what that looks like for mental health services, I want you to call member services on the back of your card.
And you wanna ask these three questions. Question number one. Do I have out-of-network benefits or coverage on my plan for behavioral or mental health services?
Now some insurances classify mental health therapy under behavioral health. So if you don't use that language, they might say no, when they really mean yes.
If you do, then ask, what is my coverage, and what is your reimbursement policy? This is where they'll tell you if you have to meet a certain out-of-pocket deductible before they start reimbursing for a portion or all of the out-of-pocket costs, similar to your car insurance.
So, for many of us, if you have car insurance, you have a deductible. So that if you end up in an automobile accident or you need to use your automobile insurance for any reason,
you have to pay up to a certain out-of-pocket cost before your automobile insurance coverage kicks in.
The same is true for health insurance coverage. And then the third question, this requires a little research.
If you already have a mental health diagnosis you want to have that actual diagnosis, and preferably the DSM-5 code that goes along with it, so that your insurance provider can lookup specifically for that diagnosis what they are willing to cover and not cover.
If you have a specific provider in mind that you're looking for reimbursement coverage for out-of-network benefits, you also wanna ask that provider, what are the codes that they use to bill for services rendered?
Now, these are not the same from discipline to discipline, and they're not always the same even from therapist to therapist.
So as an LCSW, or licensed clinical social worker, I have certain diagnostic codes for similar services provided that a psychologist would use.
But the number code that I use as an LCSW would be different than a psychologist would use.
Now, I don't know why they get so nuanced with the different insurance coverages,
but they do, (chuckles) so make sure that you are referencing the right codes when you are asking for what your insurance provider specifically reimburses for.
And if you happen to know the session rates for those codes, even better, because then you can get exact numbers.
(sighs) That was a doozy. (chuckles) So the third option is a little more complicated, and that is called a single case agreement, or sometimes referred to as an out-of-network exception.
So there may be extreme circumstances where if you don't have out-of-network coverage or the out-of-pocket cost is so extreme to access the services that you so desperately need,
your insurance may be willing to enter into what's called a single case agreement with you or the provider.
So what this means, is that even though the plan that you have previously signed up for with your insurance provider dictates that you may or may not have certain coverage options.
If you are needing to see somebody who is highly specialized or trained, or you're having difficulty locating an in-network provider.
Or their in-network providers do not work with your population, or specific issue, you may be eligible for requesting a single case agreement to work with your preferred provider.
And this is not a guarantee. It often requires a clinical letter of support. This means that you may need to take a risk,
complete a client assessment, to obtain a diagnosis, and that letter before you can start working with that provider.
For example, I happen to be one of the few therapists in this area in Connecticut where I currently practice that runs group therapies for teenagers.
Because of that, if somebody cannot find another provider to provide that level of care and support,
it's deemed medically necessary for them to engage in that level of treatment and care, then they may be eligible for pursuing that single case agreement.
Ultimately though, your insurance provider gets to decide whether they want to engage in that level of support with you or not.
0 Comments