Kyle M. Carney

156-158 Mount Auburn St,
Cambridge, MA 02138

Ins and Outs of Mental Health Insurance

Today, mental health insurance comes in all shapes and sizes. Though policies vary, the following information should show you what to look for in a typical health plan.

In a typical mental health plan, how many visits are covered?

Patients are usually covered for 20 to 30 sessions a year and are expected to pay 20 percent to 50 percent of the bill. Depending on where you live and your therapist's credentials, a session can cost anywhere from $75 to $175. Medicare, the federal health insurance program for Americans aged 65 and older, covers 50 percent of most outpatient care, with no limit on number of visits.

What will my plan cover?

This depends on your provider. Most insurance companies cover problems from anxiety and depression to relationship difficulties and social phobias. However, they are not likely to cover services for weight loss or aromatherapy. IQ tests and screenings for learning disabilities are almost never covered.

Can I see a therapist of my choosing?

It depends on your insurance plan. If you have a Health Maintenance Organization (HMO) plan or a prepaid health plan, you may choose from a limited pool of health care professionals. These professionals are in-network providers, and it may not be possible to see a therapist of your choice. If you have a Point of Service (POS) plan (also known as a Fee for Service plan), you can see any doctor in the country, and your insurance company will cover your fees. If you have a Preferred Provider Organization (PPO) plan, you must again select from a limited number of providers, but it is possible to have fees partly covered for providers who are out of network. But remember, your out-of-pocket payments will be higher. For a full description of these plans, see the glossary below.

Will I need a referral from my primary care physician?

Because some insurance companies do require a referral from a primary care physician, be sure to inquire before you start your search for a therapist.

What about drug and medication coverage? For most medications, insurance plans require a copayment as low as $5 for a generic prescription and $10 or more for a brand-name drug. What is an Employee Assistance Program, and how can I use one? Some employers set up company Employee Assistance Programs (EAP) that help workers identify and resolve personal problems, emotional struggles, family difficulties or legal problems. The visits are confidential, so the content is not disclosed to your employer. They are often free, but limited in number of sessions. Check with your employer to see if these services are offered.

Will my therapy sessions go on my record? What are the repercussions?

The matters you discuss with your therapist are confidential, with certain legal exceptions: For example, your therapist can release information if she believes you may harm yourself or others. Regardless of the reasons for your therapy, your insurance company has access to your diagnosis and appointment dates.

Do you have additional tips?

Research the pros and cons of each plan and determine which is best for you. Once you choose a plan, read your policy carefully. It is crucial that you know what your insurance company will or will not cover before you schedule an appointment. When you do choose a therapist, work with him or her to develop a treatment plan that takes into consideration the number of visits your insurance allows as well as other restrictions.


Fee-for-Service: This plan is similar to the traditional health care plan, in which insurance companies pay for the services you receive as a policyholder. You pay a premium—a monthly fee—and in turn you may choose any doctor you wish and visit any hospital for services. This plan has a deductible, which is a certain amount of money that you must spend on health care each year before the insurance kicks in. After you have spent that amount, you share payments with your insurance company based on a percentage (for example, you pay 20 percent and the insurer pays 80 percent).

HMO: Health maintenance organizations are like prepaid health plans. You are responsible for a monthly premium, and the HMO covers all care—including doctor's visits and therapy. Your choice of health care providers and facilities is limited. This group of professionals is called a network. In an HMO, you may be assigned a primary care physician, who will refer you to specialists in the network. You will be required to pay a small copayment for each visit.

POS: Point-of-service is an HMO-based plan that also allows for out-of-network visits. To use in-network providers you must have a primary care physician. A POS plan is a regional plan. Members can use services outside the HMO area, but they must reside inside the HMO area to be eligible for coverage.

PPO: A preferred provider organization combines a fee-for-service plan with an HMO. The result is national insurance coverage in which you may choose from providers on a "preferred" list and pay lower costs, or you can pay higher out-of-pocket fees in order to visit non-network providers. Therapy is generally discounted, but on a fee-for-service basis.

Public Mental Health Services: If you don't have insurance, you may be eligible to receive mental health services through a government agency. Depending on where you live, your state, county or city government may provide mental health care on a sliding-scale schedule. Fees are determined based on an assessment of your family size and income. For more information, check with your state or county Department of Health and Human Services.

Medicare or Medicaid: If you do not have access to an EAP or insurance coverage from your employer, you may be eligible for federal mental health services under Medicare or Medicaid. Although most programs are fairly standardized and coverage is based on a system of reimbursement to providers, coverage varies in each state.

Reasonable, Usual and Customary Charges: A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company. The insurance company then uses this information to determine how much it's willing to pay for a given service in your area. This means that if your doctor charges above the reasonable and customary charge, you may have to pay the remainder.

Out Of Network/Non Participating Provider: A provider who is fully licensed but chooses not to participate in the insurance network. Reimbursement for services performed are generally paid to the subscriber who will be responsible for reimbursing the provider directly. A reasonable, usual and customary fee schedule may apply. Members of the insurance plan may be billed in addition to their cost-share and deductible.