How to Check Your Mental Health Insurance Benefits Before a First Visit

Where do I find out what my plan covers?

The most direct route is the phone number on the back of your insurance card. Your plan's website usually shows benefits too, although you may need to log in to your account. A phone call has one advantage: you can ask about your exact situation instead of reading a general summary.

It can take more than one call to get clear answers, and the conversation can be tiring. You can ask someone you trust to help. If that person will speak to the insurer for you, ask the insurer how to authorize them to discuss your coverage.

What questions should I ask my insurer?

Read these out as written if that is easier. Asking about both a first evaluation and follow-up visits matters, because a plan's answer for one may not be its answer for the other.

• Is this provider in my plan's network for the state I will be in? Can you give me a list of in-network mental health providers in my area?
• Do you cover outpatient psychiatric evaluations and follow-up visits? At what rate?
• What is my deductible, and how much of it have I met this year? Does it apply to these visits?
• What will my copay or coinsurance be, both before and after I meet my deductible?
• Is there a limit on the number of visits you cover each year?
• Do I need a referral from my primary care provider first?
• Does this type of visit need prior authorization? Who has to request it?
• Are video visits covered the same way as office visits? Does it matter where I am during the visit?
• What would I pay if the provider is out of network, and would that count toward my out-of-pocket limit?
• Do you have a case manager, such as a nurse or social worker, who can help me at no charge?

What do these insurance words mean?

Insurance answers are full of terms that sound alike. The short definitions below follow HealthCare.gov, a federal source. Your own plan documents have the final say on how each one applies to you.

How do network rules change what I pay?

The type of plan you have often decides how much a provider's network status matters. Your plan documents should say which type you have. If you cannot find it, ask the insurer when you call.

• HMO: usually limits coverage to providers who work for or contract with the plan, and generally will not cover out-of-network care except in an emergency.
• EPO: covers services only if you use providers in the plan's network, except in an emergency.
• POS: you pay less for in-network providers, and you need a referral from your primary care doctor to see a specialist.
• PPO: you pay less for in-network providers, and you can see providers outside the network without a referral for an additional cost.

Does my plan have to cover mental health care?

Most health insurance plans cover mental health treatment, but not all do, and some cover only certain levels of care. That is why it helps to ask about your own plan instead of relying on a general rule.

If you bought a plan through the Health Insurance Marketplace, mental health services are an essential health benefit. These plans also have parity protections. In general, limits on mental health services, such as deductibles, visit limits or authorization rules, cannot be more restrictive than limits on medical and surgical services. Your specific benefits still depend on your state and your plan.

Employer plans and government programs may work differently, so ask your insurer what applies to you. If an answer sounds wrong, or a visit you expected to be covered is denied, ask the plan how to file an appeal or complaint.

What does DanShalom Behavioral Clinic check for me?

You do not have to do all of this alone. We check coverage before the first visit, whether you plan to come to the Sugar Land office or to use secure video from Texas, Idaho, Arizona or Maryland. The steps are simple:

1. 1Tell us your planChoose your plan on the request form or tell us by phone. You do not need to send your member ID through the website.
2. 2We verify your benefitsWe check whether the clinic is in your plan's network and what your plan says you owe: a copay, coinsurance, or the full rate until a deductible is met.
3. 3We tell you what we foundYou hear this before your visit. Your insurance company makes the final decision on what it pays, so it is also worth making your own call using the questions above.

Why do accepted plans differ by state?

Networks are set state by state, so what matters is the state you are in at the time of your visit. We accept many major plans, and the list differs from one state to the next. In some states, visits may be self-pay for now.

Our insurance and fees page lists plans by state, along with self-pay rates and the sliding scale. A plan's name on that list is not a promise of coverage, because your specific benefits still need to be confirmed. If you do not see your plan, ask us and we will check. If you have no insurance or are unsure whether to use it, read about using insurance or paying yourself.

What should I do with the answers?

Keep your notes where you can find them, and bring your insurance card to the first visit. Our new patient page lists what else to bring, and what happens after you request an appointment walks through the steps in order. The visit itself is a psychiatric evaluation, so that is the service to name when you call your plan.

Please do not let a coverage question delay urgent help. If you or someone you know is in crisis, call or text 988, or call 911 if there is immediate danger. DanShalom Behavioral Clinic is not an emergency service. Our crisis resources page lists more places to turn.