Things You'll Need:
- Willingness to become informed
- Non blaming attitude
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Step 1
If you do not know what coverage you have purchased, contact your insurance carrier to find out.
Some of the more common policies include HMO (a plan without out of network benefits- you must use and in network provider) PPO (usually have out of network benefits and may be able to use any provider anywhere if you have portability) POS (point of service) (you may have out of network benefits to use providers only in certain covered areas) -
Step 2
Find our if you even have purchased mental health benefits. Some plans only allow for an evaluation. A plan may offer limited coverage/ for example: 20 days per year or unlimited visits. Find out what your co-pay is and how many days are covered. Always find out if you have out of network benefits and what they are. Find out if you will need a pre authorization for outpatient visits with a counselor and or a psychiatrists. Some plans allow for retro authorization usually 14-30 days (depending on the plan) If you or your counselor had not obtained an authorization within the allotted time frame, you may have to write an appeal letter to the company for retro authorization. You may be liable for the fees incurred with your counselor for the uncovered/unauthorized time frame.
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Step 3
Be informed as to what your insurance offers. Here is a brief list of the different levels of care (for mental and or substance abuse) You must find out if you plans covers both - mental and substance abuse.
Outpatient (includes outpatient visits to consult with a psychiatrist for medication or a counselor)
Intensive Outpatient (intense counseling generally 3-4 days per week for several hours. Usually group counseling, some individual therapy and may include consultations with a psychiatrists (if the practice has a psychiatrist on staff)
Partial Hospitalization (usually 5-7 days per week, several hours a day/similar services to the intensive therapy) Patients usually discharged from a hospital are referred to this level of care.
Inpatient Hospitalization (hospitalization due to risks such as suicidal/homicidal tenancies, need for chemical/alcohol detoxification, etc)
Residential Treatment (Rehab) Longer term treatment (usually 30 days/depending on what the insurance covers) may include mental and substance abuse treatment in a residential facility. -
Step 4
All services are based on a medical necessity criteria. Just because you want to be in a hospital (some individuals see it as a way to escape problems, or if homeless and abusing substances as a temporary housing, does not mean that you will be hospitalized) The insurance only pays for medically necessary services. If you get denied for a service, you may be able to appeal the insurance decision.
Your insurance carries (the payor of your services) determines what services will be covered, and your employer purchases the plans after which you - the client enroll in the plan of your choice. If you plan does not cover a services, it is your responsibility to find out what plan you are signing up for. Calling your insurance and complaining about your premiums will not change the fact that you have enrolled in a policy that you should have researched to find out what it covers and what it does not. If you're unhappy with you policy, enroll in a different one if you can. Take responsibility for yourself by being an informed consumer (learn about your coverage, benefits, and medical necessity criteria for the service(S) you're seeking)
