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Insurance
benefits for mental health services have changed a lot in
recent years. These changes are consistent with the nationwide
trend to control the expense of health care. It is important
to understand your mental health care coverage so that you
can be an active advocate for your child's needs within the
guidelines of your particular plan. Here are some useful questions
to ask when evaluating the mental health benefits of an insurance
plan or HMO:
- Do
I have to get a referral from my child's primary care physician
or employee assistance program to receive mental health
services?
- Is
there a "preferred list of providers" or "network" that
you must see? Are child psychiatrists included? What happens
if I want my child to see someone outside the network?
- Is
there an annual deductible that I pay before the plan pays?
What will I actually pay for services? What services are
paid for by the plan: office visits, medication, respite
care, day hospital, inpatient?
- Are
there limits on the number of visits? Will my provider have
to send reports to the managed care company?
- What
can I do if I am unhappy with either the provider of the
care or the recommendations of the "utilization review"
process?
- What
hospitals can be used under the plan?
- Does
the plan exclude certain diagnoses or pre-existing conditions?
- Is
there a "lifetime dollar limit" or an "annual limit" for
mental health coverage, and what is it?
- Does
the plan have a track record in your area?
Some of
the language used in describing your health care plan may
be unfamiliar to you. Managed care refers to the process of
someone reviewing and monitoring the need for and use of services.
Your insurance company may do its own review and monitoring
or may hire a "managed care company" to do the reviewing.
The actual review of care is commonly known as "utilization
review" and is done by professionals, mostly social workers
and nurses, known as "utilization reviewers" or "case managers."
The child psychiatrist treating your child may have to discuss
the treatment with a reviewer in order for the care to be
authorized and paid for by your insurance. The reviewers are
trained to use the guidelines developed by your health care
plan. A review by a child and adolescent psychiatrist reviewer
usually must be specially requested.
The review
process often takes place over the telephone. Written treatment
plans may also be required. Some plans may require that the
entire medical record be copied and sent for review. Reviewers
usually authorize payment for a limited number of outpatient
sessions or a few days of inpatient care. In order for additional
treatment to be authorized, the psychiatrist must call the
reviewer back to discuss the child's progress and existing
problems. Managed care emphasizes short term treatment with
a focus on changing specific behaviors.
Preferred
providers are groups of doctors, social workers, or psychologists
which your insurer has agreed to pay. If you choose to see
doctors outside of this list, (out of network caregivers),
your insurer may not pay for the services. You will still
be responsible for the bill. Similarly, care given in hospitals
designated as "in network" is paid for by your insurance,
while care given in hospitals "out of network" is usually
not paid by your insurance and becomes your responsibility.
Even when using preferred providers and in network hospitals,
utilization reviewers still closely monitor treatment.
Another
change is the variety of services and diagnosis paid for by
different plans. In the past, only inpatient care and outpatient
care was covered by insurance. Now, depending upon your particular
plan, other services such as day hospital, home-based care,
and respite care may also be covered. These lower cost services
may offer advantages to inpatient hospitalization.
A limiting
feature of some mental health care plans is a low lifetime
maximum or a low annual dollar amount that can be used for
mental health care. (i.e. Once this amount is used, plan coverage
ends.) You, as parent or guardian, are responsible for paying
the non-covered bill. If your child/adolescent needs continued
care, you may need to seek help from your state public mental
health system. This usually means changing doctors which may
disrupt your child's care.
It is
important to understand as much as possible about your particular
insurance plan. Understanding your coverage will put you in
a better position to help your child. Sometimes you may need
to advocate for services that are not a part of your plan,
but which you and your child's psychiatrist feel are necessary.
Advocacy groups may provide you with important information
about local services. The support of other parents is also
useful and important when engaged in advocacy efforts.
Additional/related
Facts for Families, #00 "Definition of a Child and
Adolescent Psychiatrist," #24 "Know When to Seek Help for
Your Child," #25 "Know Where to Seek Help for Your Child,"
#52 "Comprehensive Psychiatric Evaluation, and # 75 "Advocating
for Your Child." For additional information see the AACAP's
Policy Statement on Psychiatric Diagnostic Evaluations. Your
Child (1998 Harper Collins)/Your Adolescent (1999
Harper Collins)
Article
#26 Updated 11/99
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