Insurance Jargon

Access Issues to Mental Health: Part 4

Insurance benefits can puzzle and confuse many members because of all the unfamiliar jargon and numbers. This blog will focus only on mental health benefits, which are often a separate coverage in addition to medical health coverage. These are the most often used terms that clients should know about their coverage.

In Network Provider: a therapist who has agreed to a contract with an insurance company to provide services and for its members. Billing is included and clients often only have to be responsible for their copay/co-insurance.

Out-of-Network Provider: a therapist who does not have a contract with an insurance company. Clients usually pay the therapist’s full fee and will receive a statement called “Superbill” to send to their insurance for reimbursement. Rates of reimbursements can range widely, depending on the plan. Clients often have to coordinate payment issues with their insurance.

Deductible: the amount that the member must pay before their insurance policy will apply their benefits. This amount is renewed at the beginning of their annual cycle. Some plans will waive the deductible for mental health services.

Co-pay: a fixed rate that the member is responsible for at each visit. This amount usually ranges from $10-$40 depending on the plan.

Co-insurance: the percentage of the fee-for-service the member is responsible for at each visit. ie: Session cost is $100 and the member has a 30% co-insurance. The member would have to pay $30, insurance will pay $70.

Pre-approval/Authorization: the process of approving a member for mental health services. Some plans require that members get a referral from their primary care physician before approving. Other plans only need the member to call ahead of time and ask for an “authorization” before receiving mental health services.

Explanation of Benefits (EOB): mailed statements of dates of service and payments

Out-of-Pocket Maximum: the maximum amount that the client is responsible for per calendar year (only for approved services)

Other notable information:

    1. For private practice therapists, location of services is “office” or “11”.
    1. OON reimbursements are usually at 20-80% of what the insurance plan considers the usual and customary rate (UCR). This rate is usually close to your therapist’s full fee rate, but not always. Most OON benefits require a deductible to be met before they will reimburse members.
    1. Carve outs: some plans will contract with another company for mental health services, make sure you get the name of the plan (ie. Magellan, Beacon, CareFirst, etc) and ask your therapist if they are “in-network” with the carve out plan. If they are not, you may not be able to access in-network benefits.
  1. EOBs are almost always sent to the subscriber’s address unless otherwise requested. If you are not the primary subscriber and you want complete privacy of your services, using insurance may not be ideal. Some plans may allow EOBs to be sent to the person receiving services instead. Call your insurance representative to inquire. More info: Young Adult on Parents’ Insurance

I hope that this four part blog series have been informational and helpful in helping you begin to understand your mental health benefits. The amount of information require some time to get used to, so don’t hesitate to ask your insurance rep for clarification. I want my clients to be well informed, so I always strive to make room for questions when discussing their insurance benefits. Clients are ultimately responsible for understanding their individual plan as each plan varies greatly from the next. Therapists can learn the basics of each company, but it is impossible for therapists to know each client’s plan inside out. It is better to get a quick start on learning the terms of your plan and avoid future headaches. 

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