Insurance Benefits
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Understanding Your Insurance Benefits

To many, health insurance has become a confusing mass of alphabet soup. Once upon a time there was only a fairly standard 80-20 indemnity plan. Now there are HMO’s PPO’s, MHO’s and “carve-outs”. How do these changes effect your mental health benefits? How do you find out about your benefits?

The insurance industry has changed to meet the cost-controlling needs of the employers. The main distinction with the mental health portion of your insurance has to do with PPO vs. Managed Care. You often will not know if you have a “managed” plan until you call the phone number on the back of your insurance card. With many insurances, such as Blue Cross HMO, Blue Shield, Cigna, United Health Care, etc., the mental health portion of the coverage is “carved out” and sub-contracted to a managed plan, such as Managed Health Network (MHN), United Behavioral Health (UBH), and Cigna Behavioral.

With a PPO, you may choose any contracted doctor and the fee will be paid at a specified rate. Co-pays tend to remain the same and there is a maximum number of sessions allowed per year. With some plans you may choose an “out of network” doctor but the deductible and co-payment rate may be more.

With managed care, you first need to call the intake department and request a referral to a “mental health specialist.” After the therapist has seen you for a number of sessions (1,3,5,10 depending on the plan) he/she must fill out and send in a form or call a reviewer to request more sessions. If the reviewer feels the treatment is “medically necessary” and fits a short-term therapy protocol, more sessions may be granted. While there is generally little or no deductible, co-payments are often graduated to higher levels as treatment continues.

While your plan may state a maximum number of sessions per year, that number of sessions may not be realized, if the case reviewer does not see the treatment as necessary. Other drawbacks to a managed care plan have to do with confidentiality and third party decision makers. Some people chose to avoid all of this and pay out of pocket.

To clarify your actual benefits, call the number on the back of your insurance card. You often will be referred to another number when you ask about “outpatient mental health.” Be prepared to give your policy number (usually the social security number of the insured), the insured’s name and the insured’s employer.

You will want to ask how many sessions are allowed per calendar year, what is the deductible and what is the co-pay or applicable percentage per session. You should ask if the therapy is “managed.” You might also want to ask if there are “out of network” benefits and what they are. With answers to these questions, you will have a better idea of what kind of therapy your health insurance actually affords.


New Parity Law  Press this link to learn how the new Parity Law may improve your ability to afford psychotherapy.

Insurance Contracts  Press this link to see which Insurance Companies our Doctors work with.



Wilmes-Reitz Psychological

23945 Calabasas Rd., Suite 202

 Calabasas, California  91302

(818) 591-8270




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