For those of you who have insurance plans that arose from the Affordable Care Act, a major benefit of those plans is that they cannot deny coverage for psychotherapy and counseling, inpatient mental health services and substance use disorder treatment, whether they are for pre-existing conditions or not. Your exact benefits are dependent on the state you live in and the type of plan you have. These policies are prohibited from putting a cap on yearly or lifetime dollar limits for essential health benefits, including mental health and substance use disorders. So, this is actually a very good thing for people who want to utilize their benefits.
For those of you who are not in ACA plans, you may or may not have mental health coverage. It’s always wise before you book an appointment to check your policy and understand your coverage. Call the number on your insurance card and ask to know what your coverage is and what the co-pays might be. If you need to get pre-approved for treatment it may take some time to do. Marriage counseling is often not considered “medically necessary” and therefore not covered.
I bring all this up for a reason. If you do choose to use your plan benefits, please be certain you have weighed the benefits you will receive against the costs. There are important consequences for you to be aware of when you use your therapy benefits.
One consequence is that whenever you submit a counselor’s statement for reimbursement from your insurance company, there is usually a diagnosis code that needs to be filled in, which reflects the counselor’s diagnosis of a mental health disorder based on the agreed upon psychological coding reference, the DSM 5. That diagnosis, once submitted, becomes a permanent record in your insurance file and is no longer strictly confidential. Anyone working with the insurance company has access to that information about you as well as anyone else those records may be sent to for their information. The ramifications of this could be significant, impacting you in ways that are not necessarily obvious. The label used most likely will not accurately describe the nuances of your mental state at the time. For example, there are many times clients come into my office feeling sad, but don’t necessarily have a depressive disorder. So you may be labeled with a disorder that is not really accurate, but you will be living with for as long as the company has your file.
Once you use your benefits, the insurance company can’t deny you mental health coverage based on your diagnosis, however certain other types of insurance such as life insurance and disability insurance coverage may be impacted should you apply for those. The reality is, you may save some money upfront by using your benefits, depending on your plan, but it might also be costing you much more in the long run by having your information shared with others sometime in the future. Depending on who else this information is shared with, this diagnosis may have the effect of narrowing some options for you down the road such as job opportunities, etc.
Insurance companies usually also want copies of your treatment plan, notes or progress reports throughout your treatment and they will usually limit your treatment to a specified number of sessions they are willing to cover. They also limit the providers you can use based on their list of in-network providers. They get to choose that-you don’t, if you use your benefits. And based on all of that information, they will decide what to cover and what not to. So the content of your therapy and the duration of it is no longer something that you and your therapist decide, unless you want to go outside of your plan. If they do decide not to cover some of it, be prepared to spend considerable time on the phone with them to argue your case. You may find yourself fighting for the same number of sessions that you would have with your regular medical doctor, according to the parity provisions.
Just consider what all of this is worth to you.
Now clearly, if you have a serious mental condition, and you cannot receive treatment without having coverage then by all means, using your insurance benefits makes sense no matter what. Receiving treatment is much more important than not getting the care you need.
Although I do not belong to insurance panels, you may still be eligible for an out of network reimbursement, depending on the plan you chose and what your company offers. If we end up working together, I am happy to give you a statement that you can submit to your insurance company who might then reimburse you with their out of network rates. Check with your carrier to see what those reimbursement rates might be.
When my clients want to use their benefits, we spend time talking about the ramifications of these issues because they are important. If they have a Flexible Spending Account I am usually happy to suggest this as a way to work with them to help pay for their couples therapy when it’s not covered by an insurance plan. I encourage you to weigh the costs and the benefits of this decision. If you do want to come in for therapy and your plan does not cover couples work, feel free to call me anyway. There may be a way we can negotiate a way to move forward with your treatment that works for you. But do think twice before you use your insurance plan to cover your therapy treatment. It may be that the potential cost of using your plan benefits is greater than what you are willing to pay.