Understanding Insurance

If you think health insurance is confusing, you’re not alone. This section is intended to help guide you through the nuances and complexities of insurance.

First, let’s breakdown what health insurance can cover in terms of mental health care. Health insurance may pay for long-term counseling, medication, emergency room visits, hospitalizations, or other services. Insurance policies vary in the amount and type of mental health care they will pay for, so it is important to become familiar with your insurance plan and be prepared to ask questions. Also, make a copy of the front and back of your insurance and prescription plan cards in case you ever lose them.

Now, let’s dive deep into breaking down this information:

Types of Health Insurance

Understanding the differences about health insurance plans can help you make an informed decision about what plan is appropriate and what options are available. The level of coverage and availability of services and mental health professionals depends on the type of plan chosen.

Common types of health insurance include:

  • Private Health Insurance: This is typically a job-based plan that you receive through your employer or through your parent’s employer if you are 26 years old or younger. Your parent can add you to their insurance during the plan’s yearly Open Enrollment Period. Your parent can also add you to an existing Marketplace plan only during the yearly Open Enrollment Period or a Special Enrollment Period.
  • Medicaid: If your income is low or you have certain life situations, you could qualify for free or low-cost coverage through Medicaid. If your state has expanded Medicaid coverage, you can qualify based on your income alone — in many states that have expanded, that’s about $16,753 for a single person, or about $22,715 for a married couple with no children. Do a quick check here.
  • CHIP: If you have children, they might qualify for coverage under the Children’s Health Insurance Program (CHIP) — even if you don’t qualify for Medicaid.
  • TRICARE and VA Health Care: If you are a uniformed service member or retiree, you and your family may be eligible for TRICARE. If you are a veteran, you may be eligible for VA Health Care.
  • Health Insurance Marketplace: A service that helps people shop for and enroll in affordable health insurance. The Marketplace offers insurance plans with savings based on your income. The federal government operates the Marketplace, available at healthcare.gov, for most states. Some states run their own marketplaces (see full list).
  • Student Health Plans: If you are returning to school to further your education, schools often offer a student health plan. Contact your college for additional information.

Self-employed? Starting a business? Work part-time?

If you’re a freelancer, an entrepreneur, a part-time worker, or self-employed, you have a few coverage options that work well for independent careers and lifestyles.

  • If you leave a job for any reason and lose job-based insurance: You can buy an insurance plan any time of year, even if it’s outside open enrollment. A plan through the Health Insurance Marketplace can be a lot more affordable than COBRA coverage, which is continued coverage provided by your former employer. You have 60 days from when the insurance ends to enroll. Learn about your options when you lose job-based insurance.
  • If you have income that’s hard to predict: You can apply with your best estimate of what you expect to make for the year. Your savings will be based on that estimate. When your income changes, you can update your application to adjust your coverage and savings. Learn about filling out an application when your income is hard to predict.
  • If you’re self-employed or starting a solo business with little income: You’ll probably qualify for low-cost insurance or free or low-cost coverage through Medicaid. When your income increases, you can adjust or change your coverage.

Navigating without insurance?

If you don’t have insurance, contact the facility where you would like to receive care to learn how much the services will potentially cost.

  • Ask if they offer a sliding scale fee. Even some health care providers that don’t advertise it may be willing to make arrangements to accommodate your financial circumstances. Ask to speak to the financial office to explore your options.
  • Sliding Scale Fee
    • You may be eligible for a sliding scale fee if you have no insurance and/or if your insurance does not cover the treatment you want. This means that the healthcare provider will charge according to what you can afford based on your household income and financial circumstances.
    • If a sliding scale fee option is available, ask the clinic what they need you to bring to your first appointment. They may ask you to bring proof of income (tax forms, pay check stubs, etc.) for your entire household with you to your first appointment.

Making an appointment

Before making an appointment, call the number on your insurance card and ask:

  • “Which mental health services are paid for by my insurance policy (i.e. office visits, medication, inpatient treatment)?” If so, will insurance pay the entire cost?” Some costs that you may be responsible for include:
    • Costs for services not covered by your insurance plan.
    • Co-pays. Most insurance companies require you to pay a small amount of the total charge (called a co-pay) each time services are accessed. Many offices expect payment at the time of service.
    • Your plan may require that you pay a set amount towards your care (called a deductible) before your insurer will cover any expenses. Find out whether your insurance plan includes a deductible and the amount of the deductible. (More information: deductibles | out-of-pocket maximums)
    • The amount of your insurance plan’s usual, customary and reasonable (UCR) coverage. Often insurers will reimburse charges at a given percent based upon the amount typically charged by health care providers for similar services in that geographic area. You can ask if a specific provider fee meets the UCR criteria (for example, “My psychiatrist fee for medication management is billed at $125. Is this within the UCR coverage?”)
  • “Do I need any approvals (such as a referral from my primary care provider, precertification or prior authorization) before the services are provided?”
    • Referrals are often necessary if you want to see a specialist (someone other than your primary care physician).
  • “Does my insurance policy pay for mental health services in my location?”
    • This is especially important if you have insurance from a different state than you live (such as a parent’s insurance), since many insurance policies only cover treatment received within a specific geographic area.
  • “Can I see the provider of my choice or is there a ‘preferred list of providers’ I must choose from? What happens if I want to see someone who is not on that list?”
  • “Is there a yearly limit on the number of counseling visits covered?”
    • Insurance plans often limit how many counseling or psychotherapy sessions they will cover in a given year. Once you exceed this limit, you are responsible for paying for the full cost of additional sessions.
  • “Does my plan exclude certain diagnoses or pre-existing conditions?”

When calling for an appointment, ask the facility where you will receive care:

  • “Do you accept Name of plan PPO OR Name of plan HMO insurance?” and “Will you bill my insurance company?”
  • “How do you bill for treatment?”
    • Even if you have insurance, you may be required to pay the entire bill and then be reimbursed by your insurance company.

Medication payment assistance

If you have concerns about how you will pay for medication:

  • Talk with your prescriber. They can work with you and will likely be aware of available medication assistance programs or can direct you to someone who can help.
  • Consider purchasing the generic brand of your medication if one is available. Generic drugs are chemically identical to their branded counterparts but are often sold at a much lower price. Ask your clinician during your visit if a generic brand is available.
  • Ask your pharmacy if they have any discount prescription programs. Pharmacies at major retailers such as Target, Kroger, and Walgreens may offer discount programs for commonly prescribed and generic medications, including psychiatric medications.

Medication Assistance Resources

  • needmymeds.org
    • Search for medication and see a list of all related patient assistance programs.
  • Patient Assistance Program
    • Free or low-cost prescription medicine provided to people with limited resources, who are uninsured or underinsured, and who meet certain guidelines. Many medicines are provided to these programs by the pharmaceutical companies that manufacture them.
Additional Resources