Difficulty Accessing Mental Health Care via Insurance 4/98

Mental Health Services

In the course of my probate practice, I have frequently recommended mental health assistance for clients, but it was not until I sought some help for a problem of my own that I really learned how difficult it can be to access suitable care and have it covered by my health insurance. Do others run into the same roadblocks?

Before “managed care,” I might have recommended that you get a referral from a trusted friend and then interview two or three potential therapists if you could. However, things have changed dramatically since then. If you are like most Massachusetts residents, your health coverage is through an HMO. In this case, the first step is to contact your primary care physician, who will determine whether mental health treatment is “medically necessary,” and a referral warranted. (Some plans offer a central mental health phone number as an alternative to the primary care physician.)

When a referral is made, it must be to a clinician who is on your HMO’s “panel,” a restricted list of providers who are employed by or have a contract with your HMO. Once you begin therapy, the HMO will probably pre-authorize something like eight sessions, based on (a) your own description of the problem and (b) psychiatric diagnosis (always required) from the professional. For additional sessions, the therapist would then provide the managed care company with more detailed information about your problem, symptoms, functioning, treatment plan, etc. In a sense, the managed care company becomes the co-treater. These companies are prohibited from sharing your personal information with others, such as life insurance companies.

You may also run across Preferred Provider Organizations (PPOs) and Point of Service (POS) health plans. These plans also have restricted provider lists, but usually will cover “out-of-network” providers, albeit at a rate that costs you proportionately more out of pocket. A third type of health insurance is “indemnity” coverage, which covers all independently licensed providers and requires no pre-authorization. This type of insurance used to be the most common but is now rare.

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