Health Insurance Basics

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. As of October 2008, federal law forbids discrimination based on mental health status by mandating that mental and physical health issues have equivalent health insurance benefits. If you have an individual policy, or you work for an employer with 50 employees or fewer, this federal law may not apply to your policy. In this case, there may be state law that mandates equivalent coverage for some diagnoses (there is in Illinois) or there may not. The state law that applies is for the state in which the policy was issued, not the state you live in. We can discuss this issue further and help you sort it out when we meet.

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? Does the deductible apply to my mental health visits? If so, how much of the deductible have I already 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 may apply this amount to my bill, if so, you would 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. Under federal law, the mental health copay should be the same as what you pay your primary care physician. 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 | Are there any limits on the number of sessions I can have per year?
(Note: Due to the recent federal law, most policies can no longer limit mental health sessions.)

5 | Do I need preauthorization? How do I get that?
(Note: Due to federal law changes, preauthorization is now rare. However, a few policies still do not let you get mental health treatment directly when you feel that you need it. They 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.)