You often don't discover what your managed care plan or health insurance plan covers until you need services. This is especially true for mental health care and substance abuse treatment. You can find out what is covered — and not covered — by asking the benefits manager in the human resources or personnel department where you work. Knowing what questions to ask can be difficult. The following list of topics and guidance may be helpful.
If you have not already received information about your health plan, ask your benefits manager for a copy of your health plan benefits; you have a right to have one of your own to keep. Does this document describe what mental healthcare and substance abuse treatment benefits you are entitled to? Does it explain how to get services and how to appeal coverage decisions you do not agree with? Does it explain what your financial responsibilities are? Is the coverage equal to that offered for other illnesses?
Ask your benefits manager which mental health professionals are covered by your plan. Does the plan cover a full range of mental health professionals? What is their training and experience? Are they licensed or certified? What kinds of treatments are available? What treatments are excluded?
Ask if there are any financial agreements or arrangements that the professional has had to make with a third-party payer or insurer that could interfere with or influence their treatment decisions. Is the professional constrained from telling you about all treatment options even those not covered in the plan? Is the professional in danger of being discharged from the plan for advocating for your optimal care? Does the plan pay the professional the same amount regardless of treatment prescribed? Does the plan reward the professional for limiting services?
Appeals and Grievances
If you have concerns about the certification or authorization of treatment decisions made by the payer or insurance company, ask how you can appeal them to the payer, your employer or the purchasing agent, or to outside regulatory agencies. Ask what methods you can use to complain if you don't agree with the care provided by the professional. You have the right to complain to regulatory boards and/or professional associations which have grievance processes, and you have the right to air your complaints to your union, your state and federal legislators and to the media.
Find out if the information to be disclosed to the payer would be anything other than diagnosis, prognosis, type of treatment, time and length of treatment and cost. Will the organizations receiving this information keep it as confidential as the mental health professional? How will they protect it? Are there penalties for disclosing information improperly? If your information is transmitted, stored, or used for any purpose as data, will information that identifies you be removed to protect your privacy? Will the information be transferred to others or sold?
Ask if you are able to choose any licensed/certified professional for your mental health care services. What professionals are covered and what are their credentials? What if you choose a licensed professional not usually covered by the plan?
Is anyone besides your professional involved in your treatment decisions? If so, do they have the same training and experience as your treating professional? Do they have a financial interest in the decisions they make?
These questions are based on a "Patients' Bill of Rights" developed by nine major mental health professional organizations to protect individuals seeking mental health treatment.