Insurance Jargon

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”.
  2. 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.
  3. 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.
  4. 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 discussion 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. If you  enjoyed this series and/or have other ideas for other topics, please let me know with a comment below!

The Cost of Access

The Cost of Access

Access Issues to Mental Health: Part 3

In 2011, 62.3% of Californians who needed mental health treatment did not receive this service (see link to data below). While insurance companies are required to provide mental health benefits, access to these benefits can range widely. Cost is a major barrier to access, even with the help of insurance benefits. Clients with spouses and/or families on their plan are often burdened with high deductibles before they can access benefits. This means that clients often have to pay out of pocket for services for months until their deductible is met and their benefits are in effect. Some deductibles are so high that it won’t be met until the last month of the year, if at all. The trend tends to be that when the monthly payments for insurance is lower, the higher the deductible rate. For individual policy holders, employer sponsored plans and university sponsored plans often have reduced deductibles to $0 deductible. More on insurance benefits in Part 4: Understanding Insurance Jargon.

Tips on managing costs for mental health services:

  • Before subscribing to an insurance plan, make sure you:
    • Understand the benefits (See Part 4)
    • Find at least 3 providers who are accepting new clients within this network
    • Estimate the medical costs and mental health costs and choose the plan that best fits your need
  • Budget and prioritize your expenses for the month/year
  • Access employer sponsored EAP services: usually 3-8 free sessions per year
  • Be prepared to pay full fee for services if you see an Out of Network therapist
  • Ask your employer if they have Health Spending Account/Flexible Spending Account options. This money is taken out pre-taxed and can be used towards mental health services.
  • Reduce chances of missed appointments or late payments with reminders
  • Ask your employer about options to make up missed work without loss of pay
  • Remember that not all quoted benefits by insurance reps are guaranteed payment, so plan for possible extra expenses.

When a therapist accepts insurance, they are providing services at 30-50% of their regular fee with required additional administrative tasks. Because of the managed care requirement, therapists often cannot see more than a set number of insurance clients per week. To do so may reduce quality of care. In addition, the standard of care is sometimes reduced to what insurance deems medically necessary rather than what the provider recommends. Additionally, most insurance plans do not cover relational issues, such as couples work. When they do cover couples, one person often must be identified as having the mental health issue to which couples therapy will help resolve. Thus, providers often opt out of working with insurance due to theses limitations. It is important to acknowledge that the medical model for mental health can be successful with certain populations, but it does not fit with all mental health issues.

The financial burden both for therapists who accept insurance and clients who need to use their insurance is a real issue that continues to go unresolved. What is clear is that more and more people are seeking therapy, thus demand continue to rise and supply continues to dwindle. It would be interesting to see where California legislation will change as talks of a single payer system is currently in the works. For more reading and data on this matter, see links below.

How to Find an In-Network Therapist

How to Find an In-Network Therapist

Access Issues to Mental Health: Part 2

Access to quality mental healthcare can come with many barriers. Cost and availability being the main issues. Mental healthcare is also different from physical healthcare because it can be subjective and does not promise results. The alliance between the client and the provider is an integral part of progress. In fact, it is the most reliable factor in predicting outcome and thus the reason for the ubiquitous mention of “best fit” (1). Mental health services can range from short term to long term depending on many factors such as diagnosis, severity, frequency of visits, financial constraints, client emotional investment, medical necessity, etc.

In the best case scenario, a client overcomes two major barrier such as finding someone who accepts their insurance and also has availability that fit with their schedule. However, the client may come to conclusion, after a few sessions, that the therapist is not a great match for them. The client is then faced with the option to stay with a provider they can afford but may not make much progress, or start back at step one and try to find another provider. Another possible scenario is if the client’s employer switches insurance and client have to decide to either stay with their current therapist who may now be out-of-network, or start the process all over again and find an in-network provider. These are very difficult decisions to make, not to mention the mental stress, time and financial investment it requires.

If this experience feels familiar, know that you are not alone. This is a common issue that many have expressed in accessing their mental health benefits. According to the Mental Health Parity Act of 2008, insurance companies are required to provide mental health benefits. However, how they provide these benefits are up to them. Carve outs and multi-payer plans cause great confusion for both providers and clients. Below are a few suggestions to help you gain access to an in-network therapist.

Tips on finding an in-network therapist:

  • Contact your insurance representative to understand your mental health benefits (See Part 3: Understanding Benefits)
  • Search online directories such as Psychology Today, Good Therapy, etc. Refine your search by insurance plans
  • Use the network’s directory (usually found on their website)
  • Contact at least 3 therapists
  • Take advantage of free consultations to get a sense of the therapist. Try not to focus on specific techniques/credentials but focus on asking yourself questions like:
    • Do I feel safe with this person?
    • Do they seem to understand my struggles?
    • Do they have experience with my issue?
    • Do they appear genuine and authentic?
  • If you’ve tried your best and still unable to find a therapist, call your network representative and ask them to search for you. This is a right you are provided as a policyholder

Difficulty accessing mental healthcare is a multifaceted issue and not one that is easily resolved within the near future. I hope this series will expand your knowledge and help you make informed decisions. Future topics on this series will include more in depth discussion of  the cost of access, understanding your benefits, and in-network vs out-of-network benefits.



Why My Practice Accepts Insurance

Why My Practice Accepts Insurance

Access Issues to Mental Health: Part 1

With the uncertain future of affordable healthcare, I will begin four part informational conversation on accessing managed mental healthcare. To keep things relevant, this series will focus primarily on the outpatient (aka office setting) private practice model of care. This series is not intended to sway clients or providers to be pro-insurance or anti-insurance. My intention is to provide factual information about this issue, a few of my personal thoughts, and to help clients make informed decisions.

Using insurance to cover mental health services has gotten easier since the Mental Health Parity and Addiction Equality Act of 2008. This law had made mental health treatment be treated in the same manner as physical health services. Without this act, mental health benefits are much harder to access both logistically for providers and financially for clients.

Due to the current political climate, this act is now in limbo as the Senate decide how healthcare will be manage and how insurance companies will play a role in the decision making process. 

Being a mental health provider who accepts insurance remains increasingly rare, especially in one of the most expensive cities in the nation. It is easy to understand why most therapists do not accept insurance, it is simply not viable to have a purely insurance based practice that is going to cover the cost of living and doing business in San Francisco. Being in-network is a lot more work for much less pay. 

However, I went into this field to help people, and in my opinion, only accepting cash pay would mean that I am neglecting a significant population in this city who cannot or will not seek mental health services they cannot afford. From a social justice standpoint, I feel that accepting insurance aligns with my philosophy of providing support where there is a need. The need for mental health services at a reduced cost will always be present. Thus, for as long as I can sustain my practice by accepting insurance, I will continue to do so. 


The Treatment Gap: An Asian American Experience

The Treatment Gap: An Asian American Experience

It is not new information that Asian Americans access fewer mental health services in comparison to the rest of the population (4). I have spent the past 5 years in my work trying to understand the patterns and trends behind the gap in treatment. I have worked with immigrants from Southeast Asia and their American born children, both from communities of poverty in southern California to tech executives and wealthy business owners in the Bay Area. The stigma of therapy is strong in the Asian culture and it does not care about social class. In my experience, this belief system continues to persist despite wealth and education.

One constant pattern I’ve noticed is that parents from both groups tend to focus very much on education and providing everything in their power to get their children to graduate from college and become a working professional. In my experience, Asian American children are often expected to be “successful” by their parent’s definition. Asians are not inherently smarter than any other race, so how does a child who is not academically inclined deal with this pressure? Who do these children become as adults?

Social media, online forums, and the expansion of quality educational health material online has helped normalize these experiences and encouraged more people to reach out for help. Despite more acceptance of therapy, mental health is still not a topic that is frequently discussed or valued in an Asian household. Until parents model mental health as a priority, the stigma of receiving therapy will continue to be passed down from generation to generation.

As someone who considers herself a part of this ethnic group, I understand the struggle it takes to recognize when things are not going well and when to seek support. Asian Americans are often not taught to seek outside help and that is one of the reasons for feelings of isolation. Parents often teach that family issues should be hidden and not shared with outsiders. Therapists are seen as outsiders, especially therapists from a different ethnic background.

Adult children of this style of parenting sometimes find themselves in situation where they are unsatisfied from working a job they don’t enjoy, confusion over their autonomy, issues with low-self worth, thoughts of suicide, and fear of disappointment. Statistics have shown that Asian Americans are 3 times less likely to seek help than their Black, Hispanic and White counterparts (1). These unresolved issues can seep into their professional and personal lives, affecting social interactions and romantic relationships.

Where does therapy play a role in all of this? Well, it really has not. Therapy can be a new and foreign place for many Asian Americans, mainly because the idea of sharing thoughts and feelings are not a natural occurring phenomenon in their household. Many have reported that it feels burdensome to share their struggles with their peers (5). Those who do share often struggle to identify how they feel and how to express these feelings.

Imagine a scenario where a teenager breaks their wrist while falling off a bicycle. It is likely that their parents will immediately take them to the ER to get an x-ray, a stint, and follow up with a cast. Now, imagine the same scenario above, but instead of breaking their wrist, the teen experiences depressive symptoms. Their energy is suddenly gone, they’re no longer interested in their hobbies, and they find themselves in a 3 hour spiral of excessive worries and self-doubt over a comment a friend had made. The parents may notice that something is “different” or even that the teen is “under performing”. They might talk to the teen, often offering solutions they think are best. For about the same cost of taking the teen to a doctor, they can take the teen see a therapist. Yet, this isn’t even a consideration for most Asian parents. Stigma remains a major barrier. Young adults have reported that their parents do not want to access therapy when they or their children are struggling emotionally. The fear of being perceived as “crazy” or “less than” can outweigh any benefits therapy may bring. Thus, these children learn to suppress their symptoms and grow up to dismiss therapy as a resource in adulthood.

Mental health issues that occur as a result of recurring pressure and stress can force the person to develop poor ways of coping. One such example I’ve repeatedly heard from clients is that they will deprive themselves of food and sleep to focus and then will “catch up” after the exam or project due date. While this tactic may temporarily work in the academic world, the professional world won’t allow for such extended relief. These same clients often find themselves in demanding positions where they have to push themselves constantly, with little room to decompress.

These seemingly harmless events of pushing limits and working overtime can bring results and success, but there is be a cost associated to those who do not take care of their mind and body. For those of you who have read this blog and found yourself relating to the issues mentioned here, please consider preventative care when it comes to your mental status. It is a lot easier to preemptively develop healthy habits to manage stress and anxiety than it is to wait until it is absolutely necessary. Therapists understand that there is a lot of hesitation and contemplation with reaching out for help. Whenever you are ready, we are here.

Sources & Further Reading: