Insurance:

Confused about how to pay for mental healthcare with your insurance? First, learn more about your coverage by following these steps:

1. Find your insurance card.

2. Call your insurance company.
   The phone number is likely on the back of your card and may be listed under "behavioral health service" or "member services." Keep in mind that some insurance companies are open 24/7 and others are only available during workday hours.
   

3. Get information about your benefits.
   a) After dialing the behavioral health services or customer call phone number, you will be connected to an operator and eventually to a representative from your insurance company. They will ask you to verify some information to ensure that you’re covered by the insurance plan. When they ask why you called, you could say, “I want to find out what benefits I have to cover mental health services."
   
   b) To learn how much your plan requires you to pay each time you go to a provider, ask how much you would pay per session. This payment is called a ‘copay’ or ‘coinsurance.’ Some insurance plans have an amount that you have to pay out-of-pocket first; this is called a ‘deductible.’ Once you pay that amount, your insurance company will cover part or all of your visit depending on your coverage.
   
   c) Insurance plans tend to vary, so it is important to look over the questions to keep in mind when learning about your insurance benefits.

Out-of-network providers are usually not covered by your health insurance policy. You typically have to pay out-of-pocket for out-of-network providers. This payment is much higher than if you go to an in-network provider. However, if your insurance company is a PPO or a POS, the insurance will pay for some of the costs of an out-of-network provider depending on their policy.

The cost depends on the type of insurance plan you have and if your provider is in-network or out-of-network. Usually, all you have to pay when you’re going to a provider covered by your insurance company is a set amount of money called a copay (around $15-35).

This amount is usually printed on the back of your insurance card. Typically, you end up paying more when going to providers that are not covered by your company (out-of-network). For more information, contact your insurance company and ask them about their rates for providers that are in-network and out-of-network.

If your insurance plan does not have any in-network providers offering in-person services near you, you should consider virtual care. As long as the provider is licensed to practice in your state, you can see them remotely. If there are no in-network providers offering virtual care in your state, you can consider searching for an out-of-network provider and checking with your insurance plan about their coverage for out-of-network care (number of sessions covered, reimbursement rates, co-pay required, among others).

Copays are flat fees that you pay during a visit to a health provider or for prescription medications. Coinsurances are similar to copays, but instead of a flat fee, you pay a percentage of the cost of service or prescription. For example, a 20% coinsurance for a $200 bill means you pay $40.

Each insurance plan has an out-of-pocket maximum and that number is the absolute maximum you have to contribute annually and this includes copays and coinsurance fees along with deductibles. Any other costs associated with your healthcare is expected to be covered by your insurance company.

Insurance greatly reduces the amount of money you pay upfront for your provider’s visits or medications. All insurance plans cover your healthcare from providers within their network, and some also cover out-of-network. Providers in your insurance company’s network can give you services for little to no out-of-pocket costs. If your insurance has prescription benefits, it will also cover all or some of the medications that you need to get from the pharmacy. For example, a $300 prescription might cost you only $10 out-of-pocket.

Insurance also greatly reduces the amount of money you pay for emergency care. Medical emergencies are extremely costly, even if it’s just the cost of checking into the hospital for one night. This cost rises if you need more intensive services, such as staying at a rehabilitation center.

The disadvantages of using insurance depend on the type of insurance plan that you have. Unfortunately, your insurance won’t cover the cost of a visit with just any provider. The most common disadvantage of using insurance is this network limitation, where most insurance companies–but not all–limit your coverage to in-network providers. Moreover, some insurance companies require you to get a referral from your primary care provider before going to specialists. Insurance companies may even limit the kind of mental health treatment you can receive. To learn more about what your insurance company covers, you can visit their website or call a representative.

You cannot be charged more or refused coverage because you have a pre-existing condition. Once you have insurance, the company cannot refuse to cover treatment on the basis of it being a pre-existing condition.

Mental health providers are required, by law, to keep your information confidential. However, if you are on your parents’ insurance plan or if they receive your medical bills and statements, they might see some information (e.g., type of service and date) on the bill. Changing the address for the bills and statements or, if on their insurance, paying out-of-pocket for the full cost of the mental health service would ensure this information is kept private from your parents.

You can file for a drug exemption request. Generally, this process requires your provider to write an explanation as to why the drug is appropriate for your mental health condition. You must wait for the exception to be approved or denied. However, it is important to check with your insurance company on their process for requesting a drug exemption because this varies by plan.

Not all health insurance companies require precertification or a referral before seeing a mental health provider. However, there are many plans that do require you to have precertification or a referral from your primary care provider. Thus, it is important to check what benefits your insurance covers beforehand.

First, make sure your insurance covers these services.

You want to make sure that the services that you are interested in getting reimbursed are within your benefits by checking your EOB. Furthermore, consider if these services are in-network or out-of-network. Some insurances will only cover in-network services, so it’s important to check if your insurance also covers services from out-of-network providers. You can find this information on your insurance’s website or by calling and talking to a representative.

Second, follow these steps to get reimbursed by your insurance.

In some cases, your provider can fill out the form to get their services reimbursed. If your provider does not fill out the reimbursement form, you will have to do this. Here are the steps to file this claim:

1. Request receipts.
   If the services are within your benefits, you will need to request itemized receipts from your provider to add to your claim.

2. Download claim.
   To get this claim you can download it from your insurance's website. This form will have further instructions regarding the logistical information needed to add to the claim.

3. Cover your bases.
   Claims may get rejected, so it’s important that the information is correct. Moreover, if a claim was lost or had slight mistakes, it’s handy to keep a copy just in case.

In most cases, your provider or hospital will request precertifications. In the event that you have to request it, you can request this online, via fax, or by talking to a representative. Requests are prioritized based on medical necessity. Mental health care and medications on the precertification list of your insurance plan can require you to notify or get a coverage determination. In the case of notification, you just have to file a form to record the mental health care service you will be receiving, but the insurance company does not have to make a decision on whether to accept to cover you. In the case of precertification for coverage determination, the insurance company will look at plan documents and clinical information to determine whether to cover that mental health care service or medication. In the case of emergency services that are on the precertification list, prior authorization is typically not required. Instead you have to notify within 24 hours or the next business day.

For example, your insurance will have a list of medications that are covered, but some are not on this list and require precertification. If you go to your pharmacy, your pharmacist will contact your insurance to get precertification. Your insurance will then request a precertification from your doctor. Your doctor will express the medical necessity of your medication, and then your insurance will decide based on a medical necessity criteria whether your insurance can cover the medication. Your pharmacy will then alert you as to whether or not your medication was approved.

Depending on where you move, your insurance policy may change. If you move to a different state, it is very important that you notify your insurance company because you may need to switch to a new plan or a different company. You can follow these steps to update your address online. You can also call your insurance and talk to a representative. If you move within your state, your plan won’t change, it is only important for you to update your address to receive mail from your insurance. However, the exception is that some HMO plans provide service coverage for specific counties, so an address change may mean going to a different facility and network of providers.

To learn more about your insurance company’s policies, you can look at the website or call to talk to a representative.

It’s important to know that some insurance companies outsource part of their mental health coverage to other companies. Again, you can look at the website or call to talk to a representative to find out if your insurance company outsources your mental health coverage.

The amount you pay for medications is based on your insurance. Some medications have a copay, some are covered in full, and some are not covered at all. There are several categories of medication: preferred, non-preferred, generic, and name-brand. Each insurance plan has a Prescription Drug List (PDL) that are preferred medications. Preferred medications have the best overall value, which is determined by your insurance and based on effectiveness and safety. Within the PDL there are “generic” and “name-brand” medications. Generic medications are copies of name-brands that work the same and have the same active ingredient, but have a lower copay. A name-brand medication tends to be prescribed if the generic equivalent is not available. This availability depends on the pharmacy and the drug. Medications are organized in tiers based on the amount you pay. The first tier has the lowest copay, and the last tier has the highest copay. The first tier is “preferred generic,” the second tier is “non-preferred generic,” the third tier is “preferred name-brand,” and the fourth tier is “non-preferred name-brand.”