WHAT YOU NEED TO KNOW ABOUT

YOUR HEALTH CARE PLAN

COVERAGE

Fortunately, most health care plans (insurance, HMO, PPO, etc.) provide some degree of coverage for mental health treatment. If you wish to use your mental health coverage, we at  Psychology Associates will work with you to obtain the coverage to which you are entitled and to file insurance claims on your behalf whenever possible. We are contract providers with  several HMOs, PPOs, and other managed care organizations. It is important, however, that you understand some of the consequences of using your mental health benefits.

There is great variability among health care plans, so the particular issues discussed below may or may not apply to your coverage. If you have questions or concerns about any of these matters, please contact your health care plan for clarification.

Pre-authorization. It is often necessary to obtain pre-authorization before receiving mental health services. This typically requires you to make a telephone call to the insurance or managed care company to provide information about the need for treatment, but different companies have different procedures. The procedure you are required to go through should be described in the material you have received from your health care plan or call the number listed on the back of your insurance card for assistance or guidance.

Confidentiality. When you use your health care plan to pay for medical or mental health services, you give up a certain amount of confidentiality. The health care plan has the legal right to know about any information in your patient record, and in fact they have the right to examine ("audit") the record itself. All insurance companies will require, at a minimum, a diagnosis and a description of the services received. Many managed care organizations require detailed information about your history and your current condition. They may ask specific questions about such things as prior treatment, alcohol and drug use, and motivation. They may request this information by telephone or in writing.

All health care plans are required by law to protect the confidentiality of patient information and they all claim to do so. When we provide information to the companies, we must assume that the information will be treated confidentially, but we have no control over what happens to the information after we release it.

Co-payments and deductibles. Benefit packages usually cover only a portion of the costs of the services that you receive. There will normally be a certain dollar or percentage amount that you are required to pay.

Medical Necessity. All health care plans state that they provide only care that is "medically necessary." Insurers have various ways to define this concept, but it usually means that (a) a diagnosable condition exists; (b) the condition is something that will respond to known treatments; (c) treatment enables the patient to make reasonable progress; (d) the service provided is not more costly than alternative services that might be available. Under most managed care plans, medical necessity is understood to include brief treatment that will quickly return the patient to a previous level of functioning. Extensive and intensive psychotherapy is rarely approved except for very severe disorders. It is possible that the health care plan's determination of what is necessary for the proper diagnosis and treatment of a condition will be different from the views of you and/or your therapist.

Non-covered Services. There are many valuable and appropriate services that will not be covered by your health care plan. Examples of services that are often not covered include the following: evaluations for educational or vocational purposes; evaluations that are required by the courts or that are for legal rather that clinical purposes; child custody evaluations; marriage counseling and family therapy unless they are part of the treatment plan for a diagnosable psychiatric condition (such as depression or alcoholism); treatment of sexual problems; treatment of long-standing personality disorders; mediation or negotiation; and experimental treatments. Your benefit plan defines what conditions and services are covered, so if you have questions about coverage you should call the plan.

Case Management. Many mental health benefit plans include requirements for case management. These may include specific treatment plans, periodic updates to the insurer, or consultations with case managers. A managed care company may at times reject a certain treatment plan or recommend a particular approach to a problem.

Utilization Review. Most health care plans have mechanisms to decide how much treatment will be covered under the plan and whether the treatment is "medically necessary." They could possibly review your case as part of their cost-control process. The company may develop a "report card" on your therapist to determine if the therapist's treatment patterns fit their conceptions of cost-effectiveness.

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