There are a number of questions that you need to ask in order to understand how much you pay and how much your insurance company pays. In most cases, health insurance policies discriminate against individuals seeking mental health services, so that you will end up paying much more out of pocket for mental health than for physical health. However, in some states (including Illinois), there is mental health parity law. This means that for certain (but not all) employers, the benefits for mental health treatment must be somewhat comparable to those for physical health. There has been action regarding mental health parity on a national level in recent years, but nothing has been finalized as of the date of this writing (June, 2008). Ask me or check a search engine for updated information.

Below is a list of questions to help you understand your mental health benefits. You should be able to find the answers in your benefit brochure or by calling the member services number on your card. You may want to print out this page to use when calling for information on benefits.

Note that these are questions for a PPO policy. A PPO is a preferred provider organization. That means that you can go see any health care practitioner you want and the policy will pay for some of it after the deductible has been met. But there will be a higher level of benefits when I am contracted with your insurance company (commonly called in-network) and a lower level of benefits if I am not contracted with your insurance company (out-of-network). If you do not have Blue Cross or Medicare, you should ask these questions specifying that you are asking about an out-of-network provider.

I have provided a note after each question to explain its importance, in case you are newer to health insurance benefits.
  1. Who covers the mental health benefits for this policy?
    (Note: Strangely, the physical health and mental health benefits for your policy may be covered by different insurance companies. In that case, you'd need to get the name and number of the company that provides the mental health services and ask them the questions below instead.)

  2. What is my deductible amount? ______ How much of that have I met? _______
    (Note: A deductible is a monetary amount that you have to pay out of pocket every year before your insurance kicks in at all. This varies a lot. It can be a smallish amount, like $100, or it can run into the thousands, depending on the policy. The insurance company will apply this amount to my bill, then you will need to pay me the deductible amount due.)

  3. What is my copay OR coinsurance for mental health sessions? ________
    (Note: A copay is a fixed dollar amount that you pay to the health care professional for each session. The mental health copay in most circumstances will be more than what you pay your physicians. Or you may have coinsurance instead of a copay. In that case, you would pay a fixed percentage of the fee. If you have coinsurance, let me know what the percentage is and I can tell you what the corresponding dollar amount is. This coinsurance fee will not vary between psychologists in the Chicago area because the payment rate is set by the insurance company.)

  4. How many sessions can I have per year? ________
    (Note: Different policies set a different number of sessions.)

  5. Do I need preauthorization? How do I get that?
    (Note: Some policies do not let you get mental health treatment directly when you feel that you need it. They will have a procedure where you need to get approval from your plan to seek this treatment. If they require preauthorization, start the process yourself if you can, or let me know if I need to do something.)

  6. Are there different benefits for serious mental illness with this policy? If so, what are the different benefits for serious mental illness?
    (Note: As mentioned above, some states have mental health parity law, mandating increased mental health coverage for some employers' health insurance policies. You should ask the question exactly as I have worded it above, because some insurance company workers are not well informed about these benefit differences and will get confused if you ask about whether parity law applies to your policy. Note that even though you may be coping effectively, it is possible that you may have symptoms that will allow you to have benefits at this higher rate. I can help you sort this out. Here is a link to states that currently have mental health parity law).
 Copyright © 2008. Jan Willer, Ph.D. All Rights Reserved.