|INSURANCE VS SELF-PAYMENT|
|Although it is difficult to generalize about insurance plans because
there is a lot of variation between insurance companies, it is useful to
discuss some of the differences. Many insurance plans are now using “Health
Maintenance Organizations” (HMO’s) or “Managed Care Companies” to control
the cost of health care. These companies promise to control costs by cutting
waste and lowering rates. If you belong to an HMO, you may only go to a
health care provider that is in their “network” of providers. They normally
will not cover the cost of any other provider (it has been found that some
HMO’s will pay benefits to providers outside of their network if asked).
You are also required to first get authorization for treatment from your
primary care physician. There are some HMO’s that now offer a “Point-of-Service”
(POS) option which allows more flexibility and the ability to choose to seek
care outside the HMO’s provider network. The HMO will provide partial reimbursement
for out-of-network services usually after a deductible has been met.
Plans using HMO’s tend to be more involved in the administration of the policy and are more restrictive because they make money by cutting costs. HMO’s contract with providers to ensure that they are not providing unnecessary services. In certain instances, therapists are given incentives to provide less or briefer treatment to clients. Some therapists are refusing to work with HMO’s because they feel they are too restrictive, require excessive paperwork to justify treatment, only authorize treatment in severe cases, and interfere in the therapist/client relationship and the process of therapy.
There is more freedom of choice with insurance plans using “Preferred Provider Organizations” (PPO’s). If you belong to a PPO, you may go to a “preferred” or “in-network” provider or an “out-of-network” provider, and they will cover a certain amount of the cost. If you go to a provider not on their list, they may require a deductible and pay a lower percentage of the cost. Some plans using PPO’s can be as restrictive as HMO’s except if you go out-of-network. Because you pay a higher percentage of the cost, they do not usually intervene in treatment decisions as much. All that is required from the therapist is a diagnosis code that meets their requirements for treatment. They do not normally ask for any other information.
Comparison of Issues
It is important for people to know the difference between using insurance versus paying for therapy on their own. Why would you pay for your psychotherapy rather than use your insurance? The issues are outlined below.
|A Note about Length of Therapy
Brief therapy works well for many people who are dealing with a temporary crisis or a specific, well-defined problem. In many instances, a therapist can help individuals or families change very quickly. However, brief therapy is not appropriate for all people or for all types of problems. If you do not feel satisfied with the results from a few sessions, longer-term therapy may prove more helpful. A Consumer Reports (November 1995) survey found that, while most people experienced some relief in both brief and longer therapies, those who stayed in therapy for more than six months reported the most improvement. Other research has found that people who stay in treatment for longer periods report greater gains than those who receive treatment for shorter periods. It takes time to develop a trusting relationship and resolve deeper, more complex, long-standing issues.
It is beneficial for you to obtain as much information as possible in order to make an informed decision regarding using your insurance benefits or paying for therapy on your own. Contact your insurance company and ask about your mental health coverage. Speak to the therapist you choose about the options you have. The therapist can also call and talk to the insurance company on your behalf. If the therapist is covered on your insurance plan, discuss with the therapist the advantages and disadvantages of using your insurance benefits. You may well choose to use your insurance until the benefits run out and then you can negotiate the cost of further treatment with your therapist. Many therapists will offer a sliding scale or reduced rate for those who cannot afford to pay the regular fee and/or do not use insurance. It is always your decision whether you want to use your insurance or pay on your own. You are encouraged to first look for a therapist based on your own likes and needs, then discuss payment options with that therapist.
Boulder Psychotherapists' Guild, Inc. (1998). Directory 1998.
California Association of Marriage and Family Therapists. Understanding your mental health coverage under managed care.
Connecticut Psychotherapists' Guild. (1999). Directory of the Connecticut Psychotherapists' Guild.
Consumer Reports. (November 1995). Mental health: Does therapy help?
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