Know Before You Go
Check your personal or family mental health coverage by calling the number on the back of your insurance card, or by logging in to your account on the insurance provider’s website. If you choose to call (recommended), be sure to have your card handy because they’ll ask you for your member or subscriber number, and likely your birthdate. Once they verify who you are, begin by asking the member service representative, “Do I have mental health coverage?”
When the customer service representative outlines your benefits, make note of your yearly deductible and how much of that deductible has already been met. Most insurance coverage will not come into effect until after the deductible has been met. It would also be a good idea to ask them about your copay.
Next, say, “I would like to see __________ (counselor) at Roubicek & Thacker. Are they an in-network or out-of-network provider?”
If the counselor or group is in-network, it means that the insurance company has a contract with that counselor to offer services to their members at specific rates. There is likely a greater percentage of the rate covered by the insurance company if the provider you would like to see is in-network.
“What is my in-network coverage for mental health, out-patient, office visits?” If you ask for exactly how much the insurance will pay, the representative will likely only offer a percentage of the allowed amount. Rarely do they offer an exact dollar amount.
If you plan on enrolling in one of our programs, LifeStar or LifeStyle Transformation, know that these programs primarily consist of weekly group sessions. In which case, ask, “Am I covered for group sessions?” If yes, then you’re good to go, and may only have to pay until your deductible is met and possibly a per-session copay.
For family or couple sessions, ask, “Do I have coverage for family or couple sessions?” If so, then your insurance will help cover those costs, again, after the deductible is met, and you may still have a copay.
Some insurance companies, based on your plan’s coverage and benefits, do not cover out-of-network mental health services. In that case, you would be responsible for the full cost of services, or may need to reference the insurance company’s list of in-network providers (sometimes called “preferred providers”) to find a counselor who is in-network.
It would also be a good idea to ask them about your copay. If they offer a percentage as copay, it may mean that you are responsible not only for the copay, but also for the remainder of the full charge after insurance has been paid. For example, say the full charge is $125 and the copay on your card states $20 is due at the time of service, so you pay it. Then, six weeks later, the insurance company pays $75. So now, $95 has been paid, but there’s a remaining balance of $30. That remaining $30 is also your responsibility. At the end of the story you have paid a total of $50 out-of-pocket, and insurance has covered the $75, equaling the total $125 charge.
What did they say? Common insurance lingo in layman’s terms:
Allowed amount: the amount recognized by the insurance company that is allowed for such services in this region. (This is where it gets tricky if your member representative tells you you only owe 10% of the allowed amount. That would be final if in-network, but when out-of-network you would owe the 10% and anything else the insurance company didn’t cover of the full charge. *see last paragraph of the Out-of-Network section above)
Benefits: The benefits are just that, benefits. You select a plan and pay for it. If you selected a plan with mental health benefits, then great, you’re covered!
Copay: for in-network coverage, it is the amount you pay out-of-pocket for each visit; typically a consistent amount
Coverage: the benefits included in your purchased plan
Current Procedural Terminology: see Service Code
Deductible: the amount you must have billed the insurance company for, and paid out-of-pocket before your coverage kicks in
Diagnosis: the terminology, definition, and code that specifies the problem or issue that brought you in for therapy. It allows the counselor to know how to best help you, and the insurance company to know whether they will cover the services or not (see also, Parity Diagnosis)
Eligibility: the services you are authorized to receive as included in your plan
Explanation of Benefits (EOB): a document that comes in response to an insurance claim submission outlining the date(s) of service, service code (i.e., individual, group, or family session), allowed amount, copay, deductible, payment amount, and other such information.
In-network: the counselor has signed a contract to be considered a “preferred” provider with that insurance company
Member: You! The person paying for, or listed as covered by, the plan
Out-of-network: the counselor has not signed a contract with your insurance company to accept their rates for services rendered
Parity Diagnosis: “The Mental Health Parity and Addiction Equity Act (MHPAEA) requires health care service plans that offer coverage for mental health or substance use disorders (MH/SUD) to provide the same level of benefits that they do for general medical treatment” (dmhc.ca.gov). According to The Mental Health Parity and Addiction Equity Act of 2008, the diagnoses that are equal to other medical coverage are listed here. https://www.dmhc.ca.gov/HealthCareinCalifornia/GettheBestCare/MentalHealthCare.aspx#.WEIRdrIrJhF
Plan: the product you’re paying for as sold to you by the insurance company
Preferred Provider: another way of saying that said counselor is in-network with a particular insurance company
Provider: the licensed counselor or group of counselors rendering mental health services
Rates: the dollar amounts charged/paid
Service Code: a five digit numerical insurance code that represents the type of service rendered (i.e., 90834 is code for an individual psychotherapy session); also called a Current Procedural Terminology (CPT) code
Superbill: *only available when the provider is out-of-network with your insurance company* a document, like a detailed receipt, listing your date(s) of service, diagnosis, service codes, amount you’ve paid for the services, and the provider’s signature; submit this to your insurance company as a claim, and they will reimburse you directly according to your plan’s benefits
Third-party Administrator: The most common one I can think of is that Magellan or Mental Health Services Administrators. Third-party administrators process the mental health claims for larger insurance companies like Blue Shield of California. There may be different in- or out-of-network statuses for these administrators (i.e. the provider may be in network with Blue Shield of California, but not with Magellan).
*Note: Insurance cannot be billed, nor would insurance pay, for services rendered by an intern or associate therapist.
It comes down to your plan
The plan you pay for on a monthly, semi-annual, or yearly basis determines the coverage you have. If you have further questions, first, call your insurance company then call us here at the office with any questions for us.