We hope the following information will make it easier for you to determine how your insurance operates when it comes to mental health coverage.
1) You will need to know if your counselor is in or out of network. If you have an HMO policy, you must use in-network providers. With a PPO policy you are free to choose out of network providers. With a HMO you will need to pre-certify mental health sessions. Also in some cases with a PPO you will also need to pre-certify. Call your insurance and ask for a code for pre-certification and ask how they handle payment for in-network providers compared to out of network providers.
2) Find out if your insurance policy has a deductible. This is the amount you have to pay before the insurance benefits kick in. See if its been met already. Also check to see if your medical and mental health deductible is combined. Once you have met your deductible, your insurance company will pay a portion of your counseling costs. The client portion may be in the form of a co-pay (set amount paid at an office visit) , a co-insurance, or both. A co-insurance is a percentage of the fee. Find out what your co-pay and co-insurance are so you will know what each session will cost you once you meet your deductible.
3) Find out what the maximum amount of sessions you are allowed to have in a year and when that year begins. Also find out the lifetime amount of mental health coverage. After the maximum amount of sessions is used up, the counselor has to certify more sessions. There is no guarantee that insurance will agree to more sessions.
* You are responsible for all of the counselors fee not paid by insurance except when the counselor has not filed a claim in time. If your counselor is out-of-network, the counselor is legally obligated to charge his or her full fee.