Mental health and your insurance

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We often don’t think about our insurance plans unless there’s a problem. We assume everything will be covered — because why else would we be paying our monthly premium? It isn’t usually until a bill arrives that we start to dig into our plan’s benefits and investigate why we’re looking at a certain dollar amount. And when you’re looking at mental health-related visits, it can be a bit tricky trying to understand how it all works.

Every insurance plan is unique, with its own set of benefits, exclusions, and stipulations. Understanding the differences can seem very daunting and overwhelming at first, but spending some quality time reading the details can go a long way in helping you take full advantage of your plan.

The ACA and mental health

When the Affordable Care Act (ACA) was enacted in 2014, it mandated coverage for many different services, including mental health care. Insurance plans are required to offer comparable benefits for both physical health — like standard sick visits — and mental health services. Any limitations or exclusions must be stipulated in the plan’s summary of benefits.

And while the coverage is mandated, it’s not always clear what company is responsible for a given visit — insurers may outsource mental health coverage to a third party. This means that a provider may be in network for most primary care services but out of network for mental health, leading to an unexpected high bill. Here’s how you can be prepared and make sure that your mental health visit is covered.

I received a bill…now what?

Talking to your primary care provider (PCP) about mental or behavioral health? A common misconception is that mental health visits are billed differently from your other primary care visits. And while that can vary depending on where you receive care, at One Medical, these visits are billed as a problem-based office visit (sometimes referred to as a “sick visit” by insurance carriers). This simply means that this visit is not billed as a preventive exam like your annual physical.

And while the coverage is mandated, it’s not always clear what company is responsible for a given visit — insurers may outsource mental health coverage to a third party. This means that a provider may be in network for most primary care services but out of network for mental health, leading to an unexpected high bill. Here’s how you can be prepared and make sure that your mental health visit is covered.

It’s important to understand that, while you may have coverage for these services, benefits may be different from other types of office visits. An office visit where you discuss knee pain may only have a copay associated with it, but a mental health visit may be subject to the plan’s deductible. Your benefits guide can be an excellent resource for learning about coverage, but if you still have questions, here are some tips for how to verify your benefits coverage.

4 tips for insurance success

When calling your insurance carrier to verify your plan’s benefits, there are four simple things to remember.

  1. Set aside time to call Member Services. Getting on the phone to talk to your health insurance company can be daunting, but it can also be helpful. If your benefits guide isn’t providing the information you need, the Member Services phone number on the back of your insurance card can be a great source of information — just make sure you have your insurance card ready or write down your member ID before calling. If you’re hoping to avoid spending a lot of time on the phone, avoid calling first thing in the morning or during lunch time. Keep time zone changes in mind, too, if you have an out-of-state plan.
  2. Check your provider’s network status. If you have a new insurance plan or are visiting a new primary care practice like One Medical, ask your insurance representative if the practice is in-network. Alternatively, you can give the representative your specific PCP’s name so they can verify if he or she is in-network.If you’re checking on mental health benefits, ask if a third-party administrator handles your mental/behavioral health benefits. If they do, you may need to call that third-party administrator to confirm network status.
  3. Verify specific benefits. Ask for your plan’s benefits for mental/behavioral health services when performed in a primary care office setting. Are these visits subject to your plan’s deductible? Do you have a copay for these visits?
  4. Confirm any exclusions or limitations. Ask the representative if any of these services are excluded from your primary care benefits. Although rare, some plans only cover mental health visits in an outpatient or hospital setting, or limit the number of visits you’re entitled to in a given year.

If you do come in for a mental health visit with your PCP and receive an unexpected bill, don’t worry — just reach out to us! Our team is here to advocate for you and ensure that everything has been processed correctly. You can send us a message on the One Medical app or give us a call anytime.

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The One Medical blog is published by One Medical, an innovative primary care practice with offices in Boston, Chicago, Los Angeles, New York, Phoenix, the San Francisco Bay Area, Seattle, and Washington, DC.

Any general advice posted on our blog, website, or app is for informational purposes only and is not intended to replace or substitute for any medical or other advice. The One Medical Group entities and 1Life Healthcare, Inc. make no representations or warranties and expressly disclaim any and all liability concerning any treatment, action by, or effect on any person following the general information offered or provided within or through the blog, website, or app. If you have specific concerns or a situation arises in which you require medical advice, you should consult with an appropriately trained and qualified medical services provider.