CABH is an out-of-network provider for insurance plans.
We are happy to help you obtain whatever reimbursement for which you are eligible.
Types of Insurance
PPO (Preferred Provider Organization)
Preferred Provider Organizations (PPOs) allow you to choose your provider. They have a network of providers who have contracted with them to work at reduced rates for promised referrals. These providers are also held to the regulations of the insurance company in providing certain frequency of services and types of services. They also often have to provide the insurance company clinical information about the patient in order to provide services. The benefit for the consumer is that they typically have to pay only a co-pay for services and do not have a deductible or a lower deductible.
Individuals with PPOs may also choose to use an out-of-network provider. They may have a deductible to meet and may pay a somewhat higher percentage of the overall cost. The benefit to the consumer is choice in providers, increased confidentiality of their clinical information, and more control along with the provider of a treatment plan.
HMO (Health Maintenance Organization)
Health Maintenance Organizations (HMOs) allow for less choice on the part of the consumer in obtaining various mental health services. The consumer must use an in-network provider in order to have insurance coverage. The benefit to the consumer is lower rates, however, they are limited in their choice of providers, the number of sessions per year they are allowed, and psychological testing is covered in a very limited way if at all.
Questions to Ask to Understand Your Insurance Plan
Sometimes mental health services are managed by a company other than your general insurance provider. Typically, you can find the number of the mental health management company on the back of your insurance card. In order to understand the limits of your mental health insurance, the following questions may assist you:
Do I have out-of-network benefits for mental health, counseling and/or psychological testing services?
If the answer is “no,” you have an HMO and will need to use someone in your network’s plan in order to have coverage for mental health services.
If the answer is “yes,” you have a PPO, and the following questions should be asked to understand your plan further:
Do I have a deductible?
What is my percentage of responsibility after my deductible has been met?
Is there a cap on what you pay per hour on mental health, counseling, or psychological services?
Do I need pre-approval in order to meet with the provider of my choice or after an initial meeting with the provider before continuing with therapy or testing services?
Considerations When Using Managed Care Providers
Lack of Confidentiality
All managed care plans involve direct clinical management by the plan’s case managers if you use an “in-network” therapist. If you access therapy through your managed care plan, it makes it necessary for your therapist to disclose anything and everything related to your case to your provider. This information is used by your insurance provider for determining benefits, which they allocate at their own discretion.
Difficulty Getting Treatment Authorized
Due to their desire to keep costs to a minimum, every insurance plan has different requirements and standards for authorizations. Some will deny therapy in lieu of taking prescription medications, which can be damaging to patients because they can be given medications that they either do not need or that are inappropriate due to misdiagnosis.
Managed care plans typically allow a certain number of treatment sessions per year for each plan, however this does not mean you can automatically access your benefits. Members are often given only one to three sessions as an assessment to start their therapy. Then you may need to wait for more visits to be authorized. Often, the managed care plan may only authorize three sessions at a time, with this continual waiting period in between authorizations. This can cause your treatment to be inconsistent, broken up, and anxiety provoking not knowing if you will in fact get your benefits authorized at all. Some clients give up on their treatment due to these frustrations.
Considerations When Using Managed Care Providers
When utilizing “in-network” providers, managed care plans will dictate which tests may be provided and whether or not they consider testing to be “medically necessary.” Managed Care Plans are primarily about cost containment and prefer medication and brief therapy treatments as opposed to thorough psychological evaluations to determine accurate diagnoses, which then dictate treatment planning. HMOs often do not cover psychological testing services at all and the PPOs will not authorize the use of some tests (i.e., academic achievement), which they perceive as being an educational evaluation as opposed to viewing it as part of looking at the “whole child/adolescent.”