Managed Care And Your Mental Health

What You Need to Know About Your Managed Mental Illness Insurance Benefits

In survey after survey, the American people have said they believe in equal care for mental illnesses and that every person needing psychiatric care should have access to a psychiatrist of their choice.

Unfortunately, many employers, in the name of controlling costs, only offer their employees a choice among managed care plans such as Health Maintenance Organizations and Preferred Provider Organizations. These systems may limit your choice of psychiatrist or other physician, and provide less care for mental illnesses than for other medical illnesses. In a recent survey, respondents regarded auto repair shops as more trustworthy than their managed care plans.

Patients who have a choice should opt for a health insurance plan offering free choice of physician, one in which all health decisions are the responsibility of the doctor and the patient. Health care today is big business. To get the best care, patients must be informed about their own health needs, must understand the details of their insurance plans, and must be willing to fight for what they deserve.

Your Benefits

Don’t assume that because you or a family member do not now have a mental illness that you don’t need good mental health coverage. One in four adults will suffer from a mental illness or substance use disorder in any year. The best plans provide the same coverage for mental illness as for other medical illness such as cancer or arthritis, subject to the same deductibles, co-pay amount, annual limits, and lifetime maximums. Unfortunately, most health plans discriminate by providing less care for mental illness, and by requiring you to pay more out-of-pocket for the care you do receive. Make sure the plan offers emergency care, including psychiatric emergencies, and will allow you to go to the nearest emergency facility.

Exclusions

Read the “fine print” in your own benefit plan and ask to see the contract between the plan and the employer. If you can’t understand its legalese, have your employee benefits manager or attorney explain it in straightforward language. Some plans will discriminate by strictly limiting the number of psychotherapy visits and days in the hospital, and may limit the type of medications they will provide or pay for. If you are joining the plan for the first time, make sure it will cover illnesses you suffered in the past or are currently being treated for. Many plans require a waiting period for pre-existing illnesses..

Choosing Your Psychiatrist

Research shows that patients do better in treatment when they choose their own psychiatrists. The American Psychiatric Association believes that all patients should be able to choose a “point-of-service” psychiatrist, although the plan may require you to pay a larger portion of the cost yourself. If your psychiatrist is not a “participating physician”, a second choice is to ask whether he or she would be allowed (or would be willing) to join the plan’s panel of physicians. The third choice, and least desirable, is to negotiate a transition period with the plan in which you remain in treatment with your current psychiatrist, but eventually transfer to the care of a “participating psychiatrist.” If you must select a plan psychiatrist, ask your treating psychiatrist to recommend one from the plan roster. Note that not all may be accepting new patients or be convenient to you.

Gatekeepers

Many plans will not allow you to make an appointment directly with a psychiatrist. They require that you first be evaluated by a “gatekeeper” - usually a family doctor, social worker, or plan service representative- to determine whether specialist care is needed. Unfortunately, gatekeepers may not be adequately trained in the diagnosis of mental illness and may miss symptoms indicating the need for care by a psychiatrist. George Anders, in his book “Health Against Wealth” quotes the mother of a seriously ill child who was mistreated by a well-known managed care plan: “We don’t need a gatekeeper if the child is in an emergency; we need all the doors to be wide open.”

Confidentiality

Your trust that confidential information discussed with your psychiatrist will not be shared with others is crucial to effective treatment. Ask how confidential information is protected and don’t sign blanket medical record release forms; only sign time-limited requests to release specific information. If the plan cannot assure you that information about your case that would identify you will not be shared without your permission, investigate another plan, or even consider contracting privately for care from a professional outside the plan who will protect your confidences.