Navigating Insurance Coverage for Mental Health Services
Before you start, here are some things to have on hand:
- Health insurance card: Have your health insurance card handy so you have the insurance company’s phone number, your Member ID number, and any other plan details you may be asked for.
- Full name and date of birth of the subscriber (the person who secures insurance). If you are on your parents’ health insurance plan, you will want to have their name and DOB prepared and ready to provide.
- If you know the provider you want to use, have the provider’s full name (Make sure to ask your provider for their full registered name. For example, while they may go by “Dr. Jess,” their full name in the healthcare system may be “Jessica Jones.”)
- Provider’s NPI: Every licensed therapist has a National Provider Identification. You can ask your therapist for this on your initial call.
- If you do not know a specific provider you would like to work with, continue with the following steps outlined below.
Once you have you information ready, you can start to research your coverage. To do this, follow these steps:
- Look at the back of your insurance card for contact information for your plan. You will find website information and toll free phone numbers. You will want to check your insurance for Behavioral Health coverage, so look for that number.
- To find if a provider is in your network, you can do a search on the insurance company’s website or call the toll free number.
- When calling, follow prompts to “Check Eligibility and Benefits” so that you get connected with the right representative.
- Once you are connected with a representative, or are on the website, check your coverage carefully by asking the following questions
- Do I have mental health insurance benefits?
- What is my deductible and has it been met?
- Does my insurance cover Telemedicine or Virtual Behavioral Health?
- How many sessions per year does my health insurance cover?
- What is the coverage amount per therapy session?
- Is approval required by my primary care physician?
5. If you know the provider you want to see, and learn that the provider is “out of network”,ask the following questions:
- What is my out-of-network deductible for outpatient mental health visits?
- How much of my deductible has been met this year?
- What is my out-of-network coinsurance for outpatient mental health visits?
- Do I need a referral from an in-network provider or a primary care physician to see someone out-of-network
- How do I submit claims for out-of-network reimbursement?
Learning the basic health insurance terms can help you find your way through health
insurance benefits. Here’s a quick rundown:
- Deductible: How much you pay out of pocket before your insurance kicks in coverage.
- Copay: A fixed amount you pay for a health-care visit or service.
- In-network: Refers to the set of health-care providers (physicians, hospitals, clinics, etc.) who accept your insurance.
- Out-of-pocket maximum (OPX): The most you have to pay in a year for covered services before your insurance starts to pay 100