[US] How to make the most of your employee mental health benefits

[Daniel E.]

In Anxious Times, Medical Help for the Mind as Well as the Body
By Lesley Alderman
New York Times
November 6, 2009

STRESSED? Depressed? Or worse?

You wouldn’t be alone. Unstable economic times can lead to unstable states of mind.

“As life becomes more unpredictable, levels of toxic stress increase,” says David L. Shern, the president of Mental Health America, a nonprofit advocacy group based in Alexandria, Va.

But when you’re worrying about money, it’s hard to spend money on getting help — as in $200-an-hour therapy sessions.

That’s how Karen Nienhauser felt. Her family had experienced considerable turmoil over the last year, and she knew they could benefit from therapy. But because she and her husband were both working only part time and money was tight. Ms. Nienhauser, who lives in Scottsdale, Ariz., did something she had never done before. The family has insurance through her husband’s part-time teaching job, so she went to the insurer’s list of approved psychologists and chose one.

In the past she would have gotten a recommendation from a friend or doctor and paid the going rate. “I used to think network therapists were not as good,” she said. “But I was wrong.” She’s delighted with her choice and the cost: just $30 a session, no matter how many family members attend.

If you have a job, and insurance that includes mental health benefits, you can find affordable care — but you need to shop wisely.

You also need to be aware that your benefits might be changing in the coming year. Because of a new federal law that takes effect for most insurance plans on Jan. 1, the Mental Health Parity Act, there is a very good chance that your mental health coverage has indeed changed — possibly for the better.

In this column I will explore how to make the most of your mental health benefits. In a future column, I’ll discuss how to find free or low-cost mental health care if you don’t have insurance.

THE CHANGES You might have noticed in the materials your employer handed out recently during open enrollment that your mental health benefits would look different in 2010. For instance, rather than being given a set number of visits, you may have unlimited visits now, but possibly with additional administrative hurdles before you can have access to the care.

That’s because of that Mental Health Parity Act, which Congress passed last year.

As of Jan. 1, the law requires that group plans covering more than 50 people provide the same level of care for mental health and substance abuse problems as for medical ones. Right now, most employer plans provide less coverage for mental health — say, by limiting the amount of visits you can make to a provider or setting higher annual deductibles than for medical care.

The law’s changes can be good and not so good. Good, because you might have access to more care. Not so good if there are new requirements, like getting precertification for coverage, that place additional barriers to getting treatment, says Kaye Pestaina, vice president of health care compliance for the Segal Company, a benefits consulting firm.

“Employees should make sure their employer provides information to them about any new medical management rules,” Ms. Pestaina said.

TRY EMPLOYEE ASSISTANCE If you need care, and your situation is not dire, consider going to your company’s employee assistance program, which might be able to arrange free counseling sessions with a nearby therapist. Often, employees are offered three or so sessions.

But Janice Dragotta, a senior consultant at the benefits consulting firm Watson Wyatt, says that the number of sessions might be more like five to eight in the coming year. “Employers want to solve problems at an early point, realizing that early intervention is critical,” says Ms. Dragotta, who is also a clinical social worker.

FOR URGENT HELP If your situation is dire, say you or a family member is dangerously depressed, call your insurer, explain your situation and ask for guidance. The plan can help match you with a therapist who specializes in the issue you are facing. In some cases, you might need to have your care preapproved by your insurer. This is often as simple as calling the 800 number and explaining what you need to the person who takes your call.

Ms. Nienhauser, for instance, talked to an insurance representative on the phone and was able to get approval for 12 months of coverage.

TRY BARGAINING The most cost-effective approach is to stay in network, because rates are lower. But what if the therapist you like is out of network? You might be reimbursed for part of that bill, but if that’s still too high for your current budget, bargain.

Yes, it’s appropriate to ask your therapist for a discount, especially if it’s for short-term therapy or as a temporary measure.

“We’ve seen requests for fee adjustments increase this year,” says Maxine Gann, a psychoanalyst who is on the faculty of the New York Psychoanalytic Institute in Manhattan. “Money should always be a topic of discussion in therapy. People should absolutely bring it up.”

IF DRUGS ARE NEEDED If you need medication to help stabilize your mood, explain to your doctor that cost is an issue. Some of the newer drugs prescribed for depression like Cymbalta, can be $100 to $200 for a 30-day supply, and your insurer will very likely charge you either a portion of that cost or a steep $30 or $40 co-payment.

But older drugs like Paxil and Prozac, in generic form, can be as little as $5 or $10 for a month’s supply. Some insurers are now insisting that doctors first try generic drugs before prescribing pricier ones, according to Ms. Pestaina. If you are seeing a network therapist, that person might bring this up without your asking.

FURTHER TREATMENT If you or a family member is in therapy and needs to be hospitalized or requires a more expensive type of treatment, ask for the “medical necessity criteria” for the condition, which insurers use to determine whether the requested treatment is medically necessary.

Under the new Mental Health Parity Act, insurers must provide you with written documentation of their criteria. This way, you will know in advance if your insurer will cover the extra treatment you believe you or your family member needs. In addition, if an insurer denies your claim, it must explain why.

BE PUSHY During times of high anxiety you need all the support you can get. Don’t be shy about using your mental health benefits, and don’t be shy about challenging your insurer if you are not getting the help you need. The new law provides people with mental health issues greater access to care — take advantage of it.

 

[Fiver]

Wow.

Until I saw this, Daniel, I'd never heard of the Mental Health Parity Act. My employer, Kroger (a large national chain grocery store in the states,) certainly falls into the category of those who my must legally comply....UNLESS my local UFCW union, which self-funds our region's Blue Cross/Blue Shield of Michigan PPO health plan, decides to remove mental health services as part of our total package because of this. It would be totally legal for them to do so, and frankly I would not be a bit surprised if they actually did drop it to save an average of $2 per insured employee. They are that petty.

My plan is pretty decent when it comes to medical coverage. For $4 a week, I'm enrolled in Blue Cross/Blue Shield of Michigan and can see any participating physician of my choice, as long as she participates with BCBSM, and nearly all docs in Michigan do. I pay a $10 co-pay for every visit to a physician or specialist, regardless if I've met my yearly deductible of $250. If I have a swollen itchy rash that's diagnosed as poison ivy, the nice receptionist says, "Here's a prescription for hydrocortisone cream which will cost the $7 prescription co-pay, and with your office visit co-pay of $10, your total is $17. No, we do not accept payment in pennies, sorry." Okay. However, if the doc looks at it and thinks perhaps I'm suffering from a rare form of New Guinea Bumpsofitchia Dermatitis, I'll hear this instead: "That will be a $15 co-pay for your prescription of Itchlikehellicillen because it does not come in a generic yet. And since you've not yet met your yearly $250 deductible, and when you asked her to scratch that itch on your back that is in the one spot that you can't reach yourself, we deemed it as a medical procedure and have coded it as such. So your total today is [clickity clickity clickty] two hundred and thirty-three dollars. Whoops! Haha, sorry my mistake. Plus your ten dollar co-pay for the office visit. Will you be paying the two hundred and forty-three dollars today by cash or chickens?" But then again, the next time I'm dumb enough to frolic naked through poisonous weeds, I'll have just a small amount left to pay on my deductible, the office visit sawbuck, and $7 for a med called Hellthisitchesmycinthat that is cheaper now because the patent expired two months ago and it's available as a generic. It is essentially no different than the Brand name, more costly Itchlikehellicillen, a new drug from the same Big Pharma, that is actually nothing more than the d-isomer of generic Hellthisitchesmycin. But I digress.

It's a very decent medical plan, if the union can't come up with a new imaginative reason to deny the claim.

But this Parity Act got me thinking about the odd co-pay for a therapy session. Before I pulled out my benefits guide ten minutes ago, what I knew was this: They will pay 80% the UCR of 30 mental health outpatients visits per calendar year and I pay the other 20%, which has worked out to be 18.97 (and they include med checks with the psychiatrist in those thirty visits.)

I was hoping it would offer an explanation as to why a therapy session, or at least a med check with an M.D., goes with the 80/20 UCR payment which ends up being nearly twenty bucks a visit, instead of the ten dollar copay that my family doc would charge to tell me I do not need an antibiotic for my stuffy nose, because hey, that's a useful way to spend ten bucks of my money and sixty-two bucks of the insurer's money if I've got nothing better to do.

I already know I have a deductible for medical services with only a $10 co-pay even if the deductible hasn't been met yet, and I'm not restricted to any arbitrary limit of outpatient appointments during the calendar year. Nor do they put a limitation on how many days per year they'll pay for inpatient care for medical reasons. I also know that for mental health treatment, I am limited to 30 outpatient visits and 30 days for psych inpatient treatment per calendar year. I didn't question the disparity between their classification of benefits, even though it seemed unfair to me that I was screwed if I needed more than six months of weekly therapy sessions. But even when I needed to start using those benefits, I didn't have time to really think about the facts as I knew them because I was busy being in desperate need of therapy.

Here's what I did NOT know that disturbs me very much, for it was never made clear at all from the benefits handbook, whereas the medical benefits are easy to understand: 1) when I was hospitalized inpatient in the psych unit, they counted each daily five-minute visit by the attending psychiatrist as an outpatient visit! Now I know why it seemed like my 30 paid outpatient appointments burned through so fast. (I am very fortunate that my therapist has the authority to slide the scale wherever she'd like, since she is the Big Cheese in Charge of the entire 11-therapist, 2-consulting psychiatrist clinic -- but she does not own it. She just bosses it around. Without the drastic reduction in weekly fees I would have been unable to continue therapy with her and it's very likely I would have not sought help via the County Mental Health Services after having established a solid relationship with Pat.)

It occurs to me that there is a very high possibility that the 30 visit outpatient cap could have resulted in my death by being suddenly left without professional guidance and medications that, as it was, were barely keeping my head above water at that time. I could not have paid $125 per session, often twice a week. I was on a medical leave of absence due to PTSD; I was drawing less than 60% of my usual weekly pay. For someone who isn't offered a sliding scale, this situation would probably be disastrous if cut off right when treatment was most needed.

But wait, I learned something else today! I understand that I am responsible for the $250 medical deductible before my insurer will pay 80% of my hangnail removals, because after all, if it's medical it deserves reimbursement. However, what I've been incorrectly assuming all along is that the same $250 deductible was applied to mental health benefits as well, since it is all paid eventually by BCBSM and coordinated through my union (a total conflict of interest, if you ask me.) Same insurance company, same benefits coordinator. same union, AND THE SAME BOOKLET DESCRIBING WHAT MY FOUR BUCKS EVERY WEEK IS BUYING ME. They explained the $250 deductible very clearly in the beginning. Except they didn't explain it clearly at all, because it was discussed in the first chapter that had the bold, 14 point eye-catching topic heading...and then at the end of the part regarding mental health coverage, in small print, at the bottom of the page where there are so many boring bullet points that it was easy to miss, obviously -- it says in tiny letters that there is a separate $250 deductible for all mental health services before the plan will pay 80% of the UCR. Another two hundred and fifty bucks for the same plan, the same insurer, the same union coordinator, and the same goddamn body that already paid $250 for needed medical services early on in the calendar year!

Ooh, let's add insult to injury here -- my therapy co-pay ends up being nearly twice as much as my physician co-pay, except that my physician and I can have as many appointments as we feel like having all year long at ten bucks a shot, but I'm paying another freaking $250 copay for mental health treatment that is only giving me the bare minimum of the therapy sessions it takes to even begin to comprehend what this complex psychiatric diagnosis is all about. WHAT?! My policy needs to add a disclaimer: Don't ever become so depressed or suicidal that you'll need acute inpatient treatment for a week or ten days, because whoops! You've just used up one third of the therapy session tokens that are the backbone of recovery, all because a psychiatrist treated you responsibly and looked in on your progress every day while you were a psych inpatient. Oh well, you should have read the booklet with a magnifying glass so as usual, your fault, not ours, so thank you and have a nice day!

This seems to me somehow to be indicative of society in general, with the idea that people with mental illness who are actively seeking treatment and recovery, or at least maintenance of their illness, are less needing of the financial ease that having health insurance (should) offer than the idiot who gets drunk and goes hood surfing on his buddy's car until the point where he falls and becomes a quadraplegic, requiring a three month ICU stay, six months in a rehabilitation center, and in need of supplies and care for related chronic medical problems until the day he dies. But hey, as long as he pays the yearly deductible of $250 he only has to pay 20% until he reaches the yearly maximum out of pocket wad of $1000. Then it's ALL covered, pal. Enjoy surfing the hood of that Toyota. You're covered.

I feel like there's a conference room full of insurance executives, and I hear their conversation in the mp3 player of my mind..."Oh my god, you know what? Mental patients are so nuts that they creep us out! Plus, most of them are just faking it to get out of some kind of responsbility. Like jail Or work mostly work, because they don't care that they can't live on what Short Term Disability pays them because they're out partying with all that money they no longer make. Anyway, I know! Let's punish them with an extra deductible! Then they'll think twice about using OUR union's money before whining to a someone who charges to listen to their neurotic little quirks. Ooh! Ooh! Don't make the thing about the additional deductible for mental health services visible unless they're really looking for, because that way we'll get back at those who are faking it, and hey, we'll also be sticking it to those losers who have to go and whine to Dr. Phil about everything because they're too weak to grow up, geeze. Yeah, that'll teach 'em. Yeah!! ALL RIGHT! HIGH FIVES ALL AROUND FOR MAKING SURE THE STIGMA SURVIVES! Woooo!"

Sorry. I'm extremely cynical at this moment. Extremely.

 

[Daniel E.]

when I was hospitalized inpatient in the psych unit, they counted each daily five-minute visit by the attending psychiatrist as an outpatient visit!

Wow. That never happened to me.

it says in tiny letters that there is a separate $250 deductible for all mental health services before the plan will pay 80% of the UCR.

Unfortunately, that does not surprise me more than it should.

 

[Fiver]

Wow. That never happened to me.

But it makes sense when you read the contract and see what is covered under Medical and what's covered under Mental Health.

On the mental health side, there are only two services covered: Outpatient services and inpatient admissions. That's is. Even med checks, a MEDICAL service provided by a licensed physician for the purpose of prescribing and monitoring powerful meds that often cause serious physical side effects, are tossed in the MH outpatient category, part of the 30 per year.

The way hospital billing works at any type of hospital is for the hospital itself to bill for its services, mainly consisting of whatever they charge per day per stay. Think about the last time you had surgery for something. How many bills did you get?

Let's see...
1. The hospital bill for taking up their space
2. A bill from the radiologist who interpreted the X-rays that determined your need for surgery
3. Yet another one from the anesthesiologist to whom you were grateful for not making you squirm during the surgery
4. And finally, your surgeon requests a little respect for his artistry in the form of Visa or Mastercard, thank you very much.

Physicians bill for their own services, separate from the hospital's bill for their services (which includes jello.)

Psychiatrists are going to bill separately, too, just like any other doctor who makes rounds. My insurer offers only two categories of covered services, outpatient treatment or inpatient hospitalization. The doc's bill logically can't be thrown into the hospital category, which only covers the hospital's services of meals, med-passing, Coloring Book Therapy, and smoke breaks, just like a medical admission (but without the smoke breaks.)

I truly hope that this isn't the standard of billing for inpatient hospitalizations for the majority of insurance packages. It's likelier that this is yet one more way that my union decided to cut costs, by further screwing over mental health benefits that are already paltry, and thereby REALLY screwing the employees for whom those benefits are vital.

Sadly, the ironic part is that our benefits program is self-funded through my union, which means that they bargain the contract with BCBSM to reimburse them, and then the union handles the actual claims and pays them out right from the their office. The organization I pay $520 a year to fight for my rights and benefits and to help with bureaucratic headaches, are also the very entity trying to cut their costs -- and deciding which claims will be paid and which will be denied. They are also to whom denied claim are appealed. I don't know how they can be an advocate for the employee when THEY are the bureaucracy when it comes to Health and Welfare benefits.

Is seems like a major conflict of interest to have a union be the self-funding disburser and having final say on claims that come out of their pockets, when they're supposed to be the employees' advocate. But it's legal.

Unfortunately, that does not surprise me more than it should.

*sigh* I know. That's why I started reading more about the Parity Act as soon as you mentioned it. It will be very interesting to see what my 2010 benefits package will not include starting January 1. And like you, Daniel, I'll not be at all surprised by how they will disappoint me with their Awesome Employee Advocacy Skillz.

 

[Daniel E.]

Mental Health and Money: For Those Without Insurance, Try These Options
By Laura L. Smith, Ph.D.

When people write to us about their problems, we often recommend consultation with a mental health professional. We can answer questions online and give some suggestions. However, we can’t diagnose or treat people without meeting them. So, we refer our readers to other sources of help.

However, far too many people tell us that they don’t have health insurance, mental health coverage, or the money for co-pays. Sadly, that is the reality today. We expect in the next few years that mental health coverage will become part of all health insurance plans.Here are a few thoughts. If you can’t afford therapy, check with the local university psychology or psychiatry department. Sometimes you can get free or very inexpensive help from a clinic. The medical or graduate students who work with you are supervised by a licensed professional. In addition, community mental health centers usually have sliding scales or reduced fees for people who cannot afford treatment.

If those options are impossible check with the local United Way for a list of support groups in your community. NAMI is an international organization that offers support and educational programs for people suffering from emotional disorders and their families. You can also find online support groups on the internet. Support groups can be extremely helpful, especially when the focus is on getting better.

Get more information. Go to reliable web sites such as psychcentral, webmd, the Mayo Clinic, American Psychological Association or American Psychiatric Association. Stay away from programs that offer quick fixes or easy cures. Check out self-help books from your public library or buy used copies (usually a few dollars plus shipping). These resources may not cure you but can get you started.

We are extremely sympathetic to your plight if finances are restricting your access to mental health care. However, we also strongly urge you to persist in your efforts to get as much help as you can. In other words, don’t allow finances to put you into a hopeless and helpless state of mind. Realize that mental health problems not only cause psychic pain, but also often lead to costly problems with physical health as well. Take care.

 

[Daniel E.]

Also, from one of the comments:

I am a therapist in a primary care clinic and FQHC Federally Qualified Health Centers are beginning to offer therapy to uninsured, under insured on a sliding scale. I guess finding these clinics is key to those needing help and unable to afford it.

Mental Health and Money | Anxiety and OCD Exposed