Health Insurance Coverage for Mental Health Services
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A good insurance plan for Mental Health coverage?
Nov 2012
We have severe OCD in our immediate family, and right now we are insured with Kaiser. Their services are ill-equipped for severity of our needs, but they make it nearly impossible to be covered outside of their network. I wanted to know if anyone has had good experiences with other providers concerning mental health coverage (psychiatrists, psychologists). We are strapped for money and relying on parents, but can't NOT go the (truly helpful, non-kaiser) doctor right now. We are willing to change providers if there are good ones out there! Stay Healthy
A helpful resource for OCD treatment is the International OCD Foundation's website. They have a treatment provider database: www.ocfoundation.org/findproviders.aspx Search options include the age of your family member (adult, teen, child), OCD treatment strategies requested (Exposure and Response Prevention, home visits), etc. The International OCD Foundation website lists OCD support groups and intensive treatment programs. Also, it has some information to help the family members of OCD sufferers think about how they can support their loved one without enabling the OCD itself - which can be a complicated balance. Best wishes, Jennifer
I used to have Cigna and it had good coverage of therapy and medication under their premium plan. There's still a deductible and I think overall coverage is limited to 30 visits/year, but it still saved me thousands of dollars and I got to see my preferred therapist. I'm now with Kaiser and paying out of pocket to stay with the same therapist and it HURTS financially. Good luck! Good insurance
I sympathize as I'm in your exact shoes. I'm the one with OCD and we have Kaiser. Their mental health services are beyond pathetic. They couldn't even diagnose me properly. I can't say enough bad things about that dept - for everything else, they've been fine. We had Health Net for a bit and I had no luck finding a decent CBT therapist who took the insurance. I finally had had enough and decided i had to pay out of pocket if i wanted to feel better. I walked into Mark Balabanis' office in Rockridge. He's expensive, but he's amazing. My OCD is SO much better - he gave me the tools I needed to combat the obsessive thoughts and compulsions. Kaiser just wanted to throw meds at me and sign me up for CBT group classes designed only to help those with generalized anxiety. I'll never be 100% since OCD isn't curable, but I'm at 85-90% and have been for about a year - and I'm med-free. Best of luck. Sympathetic
We have Anthem Blue Cross and they never give us any trouble with paying for therapy. Of course, they don't pay a large percentage but after talking with other friends it seems they may pay more than most. Good luck with this. Wendy
Listed therapists seem reluctant to accept our insurance
October 2008
Can anyone recommend a female therapist in Albany/Berkeley/El Cerrito that not only takes Blue Cross insurance...but doesn't mind taking it? I'm looking for someone who can see my teenage daughter. I took down several names from the Blue Cross WEB site and was surprised by the reception I got when I called them. The first one took three days to call me back. When she finally did, she left me a message saying she didn't take Blue Cross insurance and didn't know anyone who did. So, I called another. She called me back and left a message asking what times would work for my daughter, so I thought we were on the right track. I called her back with some possibilities and she returned that call to say that she didn't really have anything available that would work for those times (though I'd given many). I took her at her word and asked what she did have, saying that perhaps I'd have to take my daughter out of school to meet with her. She hesitated. She did come up with a time to suggest, that turned out to not work for us, but I got the distinct impression that she didn't really want to work with us. It's not me, honest! I was polite and accommodating, I promise. Has anyone else had this experience? Why do therapists list themselves with these insurance companies if they're not really interested in taking those patients? Has anyone had a good experience with Blue Cross insurance and a therapist and, if so, would you let me know who you used? Thanks. In Search of a BC Therapist
Your difficulty finding a therapist working on an insurance panel who has open slots is not an unusual problem. Many therapists work to get on insurance panels when they are early in their practices, and enjoy seeing the variety of people referred to them. However, to be in private practice, therapists need to make a fair amount of money to cover expenses, taxes and make a profit.
The reality is that being in a managed care panel means seeing clients at a much lower fee than they can charge for private fee for service. For this reason, many therapists put a limit on how many managed care cases they can have within their practice, and still have enough open slots to make a living.
What this also means is that prime time slots, like afternoons and early evenings for children and teenagers, are often reserved for fee for service clients, leaving fewer desirable time openings.
I can see why you may feel frustrated. It's reflective of a larger problem in the insurance industry, and there should be some way that therapists can communicate to their panels when they are full and not accepting new clients to help consumers avoid the frustration you are experiencing.
Another idea would be to call some place like The Psychotherapy Institute in Berkeley which has very well trained psychotherapy interns, who are very well supervised, and who see clients at lowered fees. Other lower fee community resources with therapy interns are Blue Oak Counseling Center and Jewish Family and Children's Services in Berkeley. anonymous
The anonymous post last week covered this answer well. I am a therapist who sees teens in private practice and recently decided after processing two clients with Blue Cross/Blue Shield that I am not taking any more, at least for the time being. The headache of the paperwork, spending hours (when we only have 10 min breaks) trying to get someone to resolve claims issues, and poor reimbursement rates are too problematic. This is unfortunate because some people can only afford therapy by using insurance. However, there are many private practice therapist, and low fee clinics that are willing to make therapy more affordable without going through insurance. You can ask the BC/BS providers if they would be willing get recommendations for names through BPN, or I also recommend The Psychotherapy Institute (adults and couples only), or Ann Martin Center (children) or WestCoast Children's Clinic for sliding scale therapy provided by supervised interns. Another way people reduce the financial strain is pay out of pocket and get reimbursed by their insurance (some plans will do this) or by an employer-based ''flex spending account'' that you put pre-tax wages into and then pull your reimbursement from. Anonymous therapist.
Insurance won't pay therapist - she wants me to pay
October 2005
Hi there, I have found myself in a situation with my daughters therapist that i dont know how to deal with.....the whole thing just makes me feel really uncomfortable and i need some outside perspective.
My daugter started seeing a therapist in March of this year. We are insured with Blue cross HMO and i found a MFT off their list of providers. I also DOUBLE checked with this therapist when we started that she was in fact a provider. She assured me that she was. So, fast forward to September. The therapist shows me a bill that she submitted and that was rejected for payment. That invoice only covered the first 6 sessions (she has gone once a week since march), it was for $300 and they rejected it. She asked me to call....which i did, and they said that she is NOT a provider. I got back to her.....she said she would call again and talk to them more, as she apperently has billed for other Blue cross HMO folks and is confused why she was rejected. At this point, they have not paid her for that first invoice, and im sure they wont for the months of visits that followed.
The problem is although she hasnt come out and said it clearly yet, i know that she thinks i should be responsible for a good chunk, if not all of the outstanding balance.
Where i come from is this: I found a therapist from the list spacifically because i cannot afford a private one, and whatever the reason...either she was dropped and dint know, or something, she confirmed to me that she was a provider. After that though, if i had known that they rejected her for that first bill i would have switched my daughter to another provider that was covered. The issue there is that she didnt send her first invoice for 5 months. So, we kept going (and thus racking up a bill) under the assuption that we were being covered.
I am willing to pay for some of the first bill..... i do feel really bad about the situation she is in. But, I really dont feel i should be responsible for the whole $300 ...nor any of the following invoices.
what do you think? thanks anon
I'm a therapist in private practice. Perhaps she is confusing Blue cross with Blue Shield. I believe one pays off-panel providers and one doesn't. Regardless, if I was the therapist for your daughter and this situation arose I would err on the side of the patient and not hold patient responsible. Also, waiting for 5 months to bill is not ethical--some ins. companies only give you 90-120 days to bill or they won't reimburse. I would be direct with this therapist about what you think is fair to you, and take it from there. Good luck. Another Therapist
I'm afraid you are going to be financially responsible for these bills. In future, the best source of information as far a which providers are currently contracted with any insurance company, is to contact that insurance company's Customer Service Department by phone directly yourself. Printed rosters are out of date as soon as they are printed, and individual practitioners (especially mental health, I find) are not always the most accurate source of information. Additionally, especially with mental health, services are routinely carved out by HMOs and separate vendors are used for this service (such as UBH, etc.). In such an instance, a therapist would need to be contracted with the mental health vendor, rather than the insurance company.
The therapist probably had you sign a waiver when services commenced, stating that if services turn out not to be covered, that you would be financially responsible for them. Although it is very poor billing practice (and poor financial management) for the therapist not to have billed you for five months, the reality is that if the provider is not contracted with whomever the designated mental health network is for your daughter, you are likely financially responsible for the service.
The best place for you to dispute this is with the health plan or mental health vendor, not with the provider. Good luck, and patient beware. Managed care expert
I suggest trying to work with your insurance company at this point, rather than worrying about what to pay the therapist. The therapist bills your insurance as a courtesy, but the insurance is the one making the decisions. Most insurance companies have a process in which you can contest a decision of theirs, and the rates of decision reversals can be surprisingly high! Most people just don't bother to go through the process. So, get all your ducks in a row (ie, copy of the insurance list you saw with your therapist's name on it) and call right away to start the process. Jennifer
Your daughter's therapist should know if she's been dropped as a network provider. She would have been notified by mail. I would call the number on the back of your card to find out what has happened so that you can have some clarity about how much responsibility each of you have in the matter. You said that you got her name off of a list. Was that the list from the Blue Cross website? Is it possible that she is a provider, but that the diagnosis is not covered? Your statements should have the reasons for non-payment clearly listed. In any case, it seems fair that you pay the first bill in full, 4-6 sessions, and then your co-pay ( ususally something like $15 per session ) for the remaining sessions because you would have been responsible for that amount anyway. Billing insurance companies can be confusing. They do make mistakes so it's important for you to advocate for yourself by having as much information as possible. To add to the confusion Blue Cross and Blue Shield seem to function as one company except in the state of CA. Annonymous Blue Cross therapist
This happened to me once, though not with a therapist, and I steadfastly refused to pay the bill. The office had clearly misstated their position (they'd said they were providers from a particular health plan when they weren't). As I recall, I think I also called the health plan, and they intervened. I would think, especially with a therapist, you'd want to feel trust that has now been clouded by this issue. They should not have waited 5 months before sending the first bill; that's just too long. Maybe the therapist is great, and the billing dept is just disorganized, but ultimately the doctor is in charge and should have an office that reflects the integrity you'd hope he/she has. br
I am an MFT, but don't have much experience dealing with insurance companies, so I hope others reply who do have that experience. I can see your point of view, and think that what you say makes sense. You saw this therapist because Blue Cross and the therapist said that she was a provider. It is not good business practice on the part of the therapist to not keep current with bills, say, billing at the end of the month. Showing a bill from 5 months prior, when this is different from the arrangement you entered does not sound like fair business practices. If you need advice on this, you could call the California Association of Marriage and Family Therapists, toll free at 888-89-CAMFT for advice on how to pursue this. Anon.
If the therapist was on your HMO list as a preferred provider, then that shouldn't be the reason for her not being reimbursed. Maybe the claim was denied because she waited 5 months to send in the bill. Many companies require that bills be submitted within a certain time frame - like 60 or 90 days. The other consideration is your informed consent. Did she verbally or in writing provide information about her office policies including fees and reimbursement in case of problems with the insureance company? Good Luck
Yes, I do agree that you shouldn't be responsible for the full amount. I would recommend that you explain to therapist exactly what you wrote in your posting, that you found a therapist from the list specifically because you cannot afford a private one. Explain to her that you are worried that the insurance will not cover it and it will create financial hardship for you to have to pay that amount. Most therapist work on a sliding scale anyways and she may be able to come to some affordable agreement with you. If she still insists that the insurance should cover it ask her if she is willing to call with you so that it can get resolved. Let her know how much this is bothering you (remember that she is a therapist). Maybe in the end it is an error on the insurance's part. If you'd rather not have this conversation face to face with the therapist, maybe you could call her and speak to her on the phone or leave a detailed message on her voicemail to allow her to process it. I hope it goes well and you can put this behind you.
I hope I haven't misunderstood the story, but I don't honestly see why you should be expected to pay anything but your contracted co-payments and/or deductibles. If your insurance company put the therapist's name on their list of providers in error, they, and not you, should be responsible for the resulting charges which you incurred in good faith. If the therapist's disappearance from the list was her fault in part, then she should share in the loss (as she should if her delay in billing was a contributory factor). You might consider a token payment, for the sake of goodwill, but a fairer and better thing to do would be to press your insurer to pay. It sounds to me as if your insurer has been barely ethical. Help level the field for honest insurers by not letting them get away with it.
That said, the paperwork you signed at the beginning of treatment very likely contains a clause in which you accepted responsibility for whatever the insurer doesn't pay. In that case, you could be forced to pay, and would have to press your insurer to reimburse you. Pretty fed up with insurance company antics!
I'll add my 2 cents even though there have been lots of good responses relating to how to manage the insurance/therapist issue. I am a health care provider, not a therapist, but when I work with a family I feel I have a responsibility to work WITH a family to help them and their child. It is a huge commitment to take a child to therapy, and it's hard enough to worry about whether your child is OK without being worried about bills, too. If I were the therapist I would meet the family 95% of the way, ask for whatever the usual copayment would be, and do my best to help the child complete therapy. I think that kind of goodwill always comes back to you in another form. If the money issue bothered me, I'd refer them to someone else, but gradually. I have been burned a few times, but it doesn't happen often. another opinion
I have an older teen on Medi-Cal and have also heard for many years that there is no PHP or IOP through Medi-Cal. Have you thought about going through Mental Health ACCESS to request Therapeutic Behavioral Services (TBS) instead? They provide in-home intensive treatment for a few months to try to heal an entrenched problem. In the past I have requested up to 28 hours per week and ended up being granted 22 hours. I recommend that you request it ASAP because there can be a long delay before services kick in and I believe the provider actually takes 30 days to simply observe before creating a Treatment Plan.
Here are the phone numbers for Mental Health ACCESS:
Alameda County: 1-800-491-9099
Contra Costa County: 1-888-678-7277
San Francisco: (415) 255-3737
Following up regarding conservatorship -- this is very difficult to obtain in California. It is also a double-edged sword because if you have a young adult who is out and about in the community, perhaps not making good choices, then you will still be financially liable for any bad choices that they make if they are under conservatorship. Some examples are: stealing and damaging a car, driving while intoxicated, breaking into a building, vandalism, etc. Your finances could be imperiled depending if your young adult is choosing a risky lifestyle. It may make sense for some families, but only if the young adult buys into a safe lifestyle.
Dear Penelope:
I am sorry to hear about your daughter's challenge.
I have an adult son, who was diagnosed with a low-level of bipolar, at the age of 17--. Up until he reached 30, all was managed, without medication --he chose to bicycle and jog, stayed away from sugar and alcohol, stopped cigarettes, but then came the pandemic & once he started drinking again, but most importantly, vaping, his bipolar ups/downs became HIGH level--Today, that's where we are. Husband & I turned to NAMI (National Alliance on Mental Illness) . Are you connected with the East Bay chapter of NAMI?? Classes are offered to friends/ family members--free of charge. Apart from the 'family to family' classes there are regular monthly meetings for family, friends and separate gatherings for the 'client'--yes, including children (sorry, I'm unsure how old the child must be). Please reach out to them (located on Stannage in Albany). My experience is there is a wealth of experience and know-how for getting help for yourself and for your loved one. https://namieastbay.org/what-we-offer
All the best!
I am so sorry to hear the pain your child and family is in. I wish you all the best in navigating these issues. I recently researched therapists for my daughter and found this organization: Bay Area Clinical Associates (https://www.baca.org/). They mention on their website that they are working toward being able to accept Medi-Cal. You could contact them to see how far along in the process they are.
So sorry to hear about your daughter's challenges. My daughter has a complex set of mental health struggles and diagnoses, she has been hospitalized numerous times. Your daughter's school district should be a funding source. She will need an IEP for Emotional Disturbance. If you are interested in considering a residential program, the school district should cover the entire amount which will be around 13K-15K per month and will be a 10-18 month stay. The school district receives federal money for this. Even if you decide not to go the residential route, it might be helpful to do some research and talk to a couple of programs to get an idea of what they provide and how it works. There are a lot of programs in Utah. A great resource for information is DREDF (Disability Rights Education and Defense Fund), they have an office in Berkeley and do most communication by phone. You will need a lawyer to set up a conservatorship, most lawyers will do an initial 20-30 minute phone call with you for free. Good Luck.
I’m sorry to hear your daughter is struggling so much, I too have a teen daughter who is dealing with a serious mental illness and know acutely how hard it is to find appropriate help!
I don’t have any answers to your specific question but have 3 things to suggest that might be helpful.
NAMI is a wonderful organization that offers support groups (currently weekly on zoom) and members may have recommendations.
Willows in the Wind is another support group for parents with kids who have mental health issues and addiction I think?
There is a place with looking into called The Felton Institute. It’s only for early psychosis but offers ongoing support in a wraparound way.
I encourage you to get as much help as you can before she turns 18 and can refuse treatment.
in case she is resistant, you may benefit from the book I’m Not Sick, I don’t Need Help by Xavier Amador. Look up his Ted talk about anosognosia.
lastly there is a group called FASMI who is working to push for better services and support for seriously mentally ill. There are many parents in this group who would understand though many have adult children.
best of luck, I’m in it too and it’s awful, And COVID has made it monstrously worse. Wishing your family all the best!
Hi, my daughter started having severe mental health problems around the same age. We don’t have medi-cal so I have no experience with that but might be able to help navigate. I have dealt with 4 hospitals, numerous therapists and inpatient and my insurance company. My daughter has been inpatient, IOP and PHP. Please feel free to email me (ask the moderator for my info). I’m happy to help. I found it was vital to have support as well. My daughter is now 19.
I am so sorry you are going through this and have run up against all of these financial barriers in mental health access. As a family physician myself, I know that partial programs are a rare resource, so this is not an easy world to navigate. Your Medi-Cal managed care plan should have a patient navigation service, and some counties also have a patient navigation service usually embedded in their county’s healthcare delivery system (ex. Alameda Health Services in Oakland). Within these systems you often find more robust support for mentl health, especially medical social workers experienced with Medi-Cal, because these systems care for most of the patients with severe mood and other paych disorders. Berkeley doesn’t have such a system, but I would imagine Lifelong FQHC system as similar support. Those most experienced at navigating this system are often academic child and adolescent psychiatry residency programs, where their attending physicians, residents and fellows are actively working in the outpatient, partial and inpatient settings. Thus, they know the criteria for admission, what is required to get the admission coveredc and the likely benefit for treatment at the various facilities. They may be able to arrange for a “direct admit” to a given program, where they place the admission orders from the clinic until the care of the child is assumed by the physician who is actually on service at the partial program or hospital.
Hi, I'm sorry your family has been going through all of this. My daughter went through a local PHP virtually (Rogers) during COVID and it didn't really help. Hopefully they are starting to meet in person. You didn't mention the specialty area that your daughter needs help with so it's hare to see if the program we tried would help. I called SO many programs, so I understand your frustration.
On another note - again, without knowing anything about your child, we have found a diagnoses called PANS and PANDAS which causes psychiatric illnesses and since you've tried so many things already and they haven't worked, I'm wondering if these diagnoses may be something you can look into as they have a different treatment.
All the best.
I sent your post to child psychiiatrist friends of mine, and I hope their responses might be helpful:
“This person needs to speak to the child’s psychiatrist. The referral to higher level of care would come from them. Most partials take Medicaid.”
“Agree, talk with the kid’s psychiatrist, assuming she has one, as something underlying the relapse is not getting treated. If she does not have one, now would be the time to get one or get a second opinion. The parent may want to check through their insurance or the Psychology Today Therapist finder. This tool has separate search capabilities for physician psychiatrists- I would not revommend a psych NPs for this patient. It can filter by location, insurance accepted, etc. Parent may also want to connect to the local chapter for NAMI for helping navigating resources in the area. Agree with COVID not helping any of this. Has made it much harder.”
Hey Penelope,
I am so sorry to hear you’re having such a difficult time. I am not a parent with experience in this area but I do know of this organization that may be able to be of help. They work with families who are having difficulty accessing appropriate mental health services for children.
https://www.mhautism.org/
I am not sure if they will be helpful in your specific case but just figured I’d share the resource.
Take care!
Thank you so much to all who have taken the time to respond. I feel better knowing there are individuals out there who have been through similar situations and who want to help. I have to say my daughter has full support team. She has had counseling at UCSF, UCSF Benioff, Pathways Girls Inc, TBS. We currently have a county case worker, she has an IEP with a 1:1 aide and a psychiatrist and therapist who are really awesome. The problem is, my daughter finds it so hard to communicate. I really feel her anxiety has gotten to a level that is unbearable for her. She is showing signs of OCD and already has a diagnosis of " unspecified psychotic disorder" and anxiety disorder. She continues to state that she has made a mistake and needs to know how to fix it. This has gone on for 30 plus days.
On another note, I have gotten some more clarity on the insurance. First, we had a private plan with Kaiser before 2017 that made things a lot easier in terms of referral. NOW, We have Alameda Alliance, however, since we have been Kaiser Patients for so long, they allowed us to continue with them as the primary provider. Unfortunately, Kaiser only treats mild to moderate cases of psychosis so then we were referred to CHO. However, at this point when I am trying to get her to Next Level of care, Kaiser is pointing the finger at Alameda Alliance, Alameda Alliance has stated Beacon is in control. After contacting Beacon, we were told to contact Kaiser again. I asked our Pediatrician for a referral to an PHP or IOP an she went to the "chief of psychiatry" at Kaiser and he referred her back to Alameda Alliance. At this point I don't know who covers what. I am caught up in red tape and my daughter is paying the price. I have registered with Nami and hope to find some help. I have been to several meetings with them in the past, however I felt like no one could understand my situation because everyone suggested that a 9 year old could not become psychotic or schizophrenic. The illness stared at age 9 with paranoia and delusions and has progressed from there. She also got her first period about the same time. Will keep trying.... I plan to file a grievance with Kaiser. Any help would be appreciated
Any help would be appreciated.
Penelope
My heart goes out to you--so painful and difficult. I asked a friend who has many years of child development/psychiatry practice in Sonoma.
She said "If this were Sonoma County, I’d call the Sonoma County Mental Health Access Team. They provide services for kids on Medi-Cal (psychiatrist, case manager, wrap around services, some kids have gotten home visits and therapy).
She needs to access all the outpatient services that can be offered….that might help and if not, if she can’t be served in a public school, sometimes the school will split the cost
You kind of have to fail full outpatient services first before partial day or residential. This woman needs an advocate!
(Since it sounds like she hasn’t accessed that.)
Hi Penelope -
This sounds so hard. If you need help with the complaint process or figuring out who should cover what, I would suggest contacting the Health Consumer Center at Bay Area Legal Aid: https://baylegal.org/what-we-do/health-care/health-care-access/. Phone # is 1-855-693-7285.
Hi Penelope, I feel for your daughter! It sounds like she is struggling with a lot of different symptoms. I am a mental health professional working in Contra Costa County at a psychosis specialty program that also treats kids with at-risk symptoms including hallucinations and paranoia. It offers intensive services in line with Coordinated Specialty Care (CSC). I wonder if Alameda has a similar specialty psychosis program through the county. I know Kaiser has similar programs but not as fully fleshed out as our program. In terms of her current symptoms, that does sound like OCD, though her psychiatrist I’m sure would weigh in on that. If it is OCD, Rogers does have IOP and PHP programs focused specifically on OCD, but I believe they only take private insurance. Not sure if Kaiser has a contract with them or not. In general, my understanding is that you would have to switch to a private commercial health insurance to be covered for most IOP or PHP programs. At least in Contra Costa County, Medi-Cal doesn’t cover these kinds of programs and instead the county programs utilize wraparound, TBS, and other intensive outpatient services. Hope this is helpful…
Hi Penelope, I’m sorry you’re having to deal with this. I am too. My daughter is almost 17 and is engaging in some drugs and a fair amount of nonsuicidal self harm. A lot of stuff I really don’t understand. This is especially frustrating when it’s so hard to get in touch with experts to consult. I have spent the last three weeks calling, inquiring and filling in Web forms. I have created a spreadsheet of the resources that I have contacted so far. And more that I have not contacted yet. It is by no means comprehensive, but I would be happy to share it with you. Please ask the moderator to give you my email and I can send it to you in an attachment.
For the sake of my daughters privacy I have asked BPN to hide my user name. But I hope this doesn’t prevent them from sharing my contact info with you