BEING PREPARED
Understanding Your Mental Health Insurance

Articles for Parents
All Family Resources
Alphabetical List
  1. Children and Divorce
  2. Teenagers with Eating Disorders
  3. Teens: Alcohol and Other Drugs
  4. The Depressed Child
  5. Child Abuse - The Hidden Bruises
  6. Children Who Can't Pay Attention
  7. Children Who Won't Go to School
  8. Children and Grief
  9. Child Sexual Abuse
  10. Teen Suicide
  11. The Child with Autism
  12. Children Who Steal
  13. Children and TV Violence
  14. Children and Family Moves
  15. The Adopted Child
  16. Children with Learning Disabilities
  17. Children of Alcoholics
  18. Bedwetting
  19. The Child with a Long-Term Illness
  20. Making Day Care a Good Experience
  21. Psychiatric Medication for Children and Adolescents Part I: How Medications Are Used
  22. Normality
  23. Mental Retardation
  24. Know When to Seek Help for Your Child
  25. Who can be contacted to seek Help for Your Child
  26. Know Your Health Insurance Benefits
  27. Stepfamily Problems
  28. Responding to Child Sexual Abuse
  29. Psychiatric Medication for Children and Adolescents Part II: Types of Medications
  30. Children and AIDS
  31. When Children Have Children
  32. 11 Questions to Ask Before Psychiatric Hospital Treatment of Children and Adolescents
  33. Conduct Disorders
  34. Children's Sleep Problems
  35. Tic Disorders
  36. Helping Children After a Disaster
  37. Children and Firearms
  38. Bipolar Disorder (Manic-Depressive Illness) in Teens
  39. Children of Parents with Mental Illness
  40. The Influence of Music and Music Videos
  41. Substance Abuse Treatment for Children and Adolescents: Questions to Ask
  42. The Continuum of Care
  43. Discipline
  44. Children and Lying
  45. Lead Exposure
  46. Home Alone Children
  47. The Anxious Child
  48. Problems with Soiling and Bowel Control
  49. Schizophrenia in Children
  50. Panic Disorder in Children and Adolescents
  51. Psychiatric Medications for Children and Adolescents Part III: Questions to Ask
  52. Comprehensive Psychiatric Evaluation
  53. What is Psychotherapy For Children and Adolescents?
  54. Children and Watching TV
  55. Understanding Violent Behavior in Children & Adolescents
  56. Parenting: Preparing for Adolescence
  57. Normal Adolescent Development - Middle School and Early High School Years
  58. Normal Adolescent Development - Late High School Years and Beyond
  59. Children Online
  60. Obsessive-Compulsive Disorder in Children and Adolescents
  61. Children and Sports
  62. Talking to Your Kids About Sex
  63. Gay And Lesbian Adolescents
  64. Foster Care
  65. Children's Threats: When are they serious? 
  66. Helping Teenagers with Stress
  67. Children and The News
  68. Tobacco and Kids
  69. Asperger's Disorder
  70. Posttraumatic Stress Disorder (PTSD)
  71. Multiracial Children
  72. Children with Oppositional Defiant Disorder
  73. Self-Injury in Adolescents
  74. Advocating for Your Child
  75. Pets and Children
  76. Helping Your Teen Become a Safe Driver
  77. Grandparents Raising Grandchildren
  78. When a Pet Dies
  79. Obesity in Children and Teens
  80. Bullying #80
BEING PREPARED
Understanding Your Mental Health Insurance

Insurance benefits for mental health services have changed a lot in recent years. These changes are consistent with the nationwide trend to control the expense of health care. It is important to understand your mental health care coverage so that you can be an active advocate for your child's needs within the guidelines of your particular plan. Here are some useful questions to ask when evaluating the mental health benefits of an insurance plan or HMO:

  • Do I have to get a referral from my child's primary care physician or employee assistance program to receive mental health services?
  • Is there a "preferred list of providers" or "network" that you must see? Are child psychiatrists included? What happens if I want my child to see someone outside the network?
  • Is there an annual deductible that I pay before the plan pays? What will I actually pay for services? What services are paid for by the plan: office visits, medication, respite care, day hospital, inpatient?
  • Are there limits on the number of visits? Will my provider have to send reports to the managed care company?
  • What can I do if I am unhappy with either the provider of the care or the recommendations of the "utilization review" process?
  • What hospitals can be used under the plan?
  • Does the plan exclude certain diagnoses or pre-existing conditions?
  • Is there a "lifetime dollar limit" or an "annual limit" for mental health coverage, and what is it?
  • Does the plan have a track record in your area?

Some of the language used in describing your health care plan may be unfamiliar to you. Managed care refers to the process of someone reviewing and monitoring the need for and use of services. Your insurance company may do its own review and monitoring or may hire a "managed care company" to do the reviewing. The actual review of care is commonly known as "utilization review" and is done by professionals, mostly social workers and nurses, known as "utilization reviewers" or "case managers." The child psychiatrist treating your child may have to discuss the treatment with a reviewer in order for the care to be authorized and paid for by your insurance. The reviewers are trained to use the guidelines developed by your health care plan. A review by a child and adolescent psychiatrist reviewer usually must be specially requested.

The review process often takes place over the telephone. Written treatment plans may also be required. Some plans may require that the entire medical record be copied and sent for review. Reviewers usually authorize payment for a limited number of outpatient sessions or a few days of inpatient care. In order for additional treatment to be authorized, the psychiatrist must call the reviewer back to discuss the child's progress and existing problems. Managed care emphasizes short term treatment with a focus on changing specific behaviors.

Preferred providers are groups of doctors, social workers, or psychologists which your insurer has agreed to pay. If you choose to see doctors outside of this list, (out of network caregivers), your insurer may not pay for the services. You will still be responsible for the bill. Similarly, care given in hospitals designated as "in network" is paid for by your insurance, while care given in hospitals "out of network" is usually not paid by your insurance and becomes your responsibility. Even when using preferred providers and in network hospitals, utilization reviewers still closely monitor treatment.

Another change is the variety of services and diagnosis paid for by different plans. In the past, only inpatient care and outpatient care was covered by insurance. Now, depending upon your particular plan, other services such as day hospital, home-based care, and respite care may also be covered. These lower cost services may offer advantages to inpatient hospitalization.

A limiting feature of some mental health care plans is a low lifetime maximum or a low annual dollar amount that can be used for mental health care. (i.e. Once this amount is used, plan coverage ends.) You, as parent or guardian, are responsible for paying the non-covered bill. If your child/adolescent needs continued care, you may need to seek help from your state public mental health system. This usually means changing doctors which may disrupt your child's care.

It is important to understand as much as possible about your particular insurance plan. Understanding your coverage will put you in a better position to help your child. Sometimes you may need to advocate for services that are not a part of your plan, but which you and your child's psychiatrist feel are necessary. Advocacy groups may provide you with important information about local services. The support of other parents is also useful and important when engaged in advocacy efforts.

Additional/related Facts for Families, #00 "Definition of a Child and Adolescent Psychiatrist," #24 "Know When to Seek Help for Your Child," #25 "Know Where to Seek Help for Your Child," #52 "Comprehensive Psychiatric Evaluation, and # 75 "Advocating for Your Child." For additional information see the AACAP's Policy Statement on Psychiatric Diagnostic Evaluations. Your Child (1998 Harper Collins)/Your Adolescent (1999 Harper Collins)

 

Article #26 Updated 11/99

All Family Resources wishes to thank the (AACAP) for giving us permission to use this article.

The American Academy of Child and Adolescent Psychiatry (AACAP) represents over 6,900 child and adolescent psychiatrists who are physicians with at least five years of additional training beyond medical school in general (adult) and child and adolescent psychiatry.

Facts for Families is developed and distributed by the American Academy of Child and Adolescent Psychiatry (AACAP). Facts sheets may be reproduced for personal or educational use without written permission, but cannot be included in material presented for sale. To order full sets of FFF, contact Public Information, 1.800.333.7636.  Free distribution of individual Facts sheets is a public service of the AACAP Special Friends of Children Fund. Please make a tax deductible contribution to the AACAP Special Friends of Children Fund and support this important public outreach. (AACAP, Special Friends of Children Fund, P.O. Box 96106, Washington, D.C. 20090).
   
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