Mental Health and Substance Abuse Benefits in Managed Care

Source: AARP.org | August 14, 2006

Most managed care plans offer mental health and substance abuse benefits that cover illnesses such as depression, alcohol or drug addiction. However, these benefits often are far more limited than your other medical benefits and often cost more.

To find out about you plan's mental health and substance abuse benefits, contact your doctor, your plan's member services department or help line for information about seeing a mental health or substance abuse counselor. Ask:

• How many visits to a mental health or substance abuse counselor will your plan pay for? Many plans limit the number of visits they will pay for in one year.
• Do you need a referral from your primary care doctor before you can see a mental health or substance abuse counselor?

If you are in a health plan through your employer, see if your employer provides mental health benefits through some arrangement other than your managed care plan. For example, some employers offer counseling and support services through an employee assistance program.

Care Outside of a Hospital

Treatment for mental health and substance abuse that takes place in a counselor's office and not in a hospital is called outpatient care. Most managed care plans pay only for a limited number of office visits to a mental health or substance abuse counselor.

• Many plans pay for up to 20 individual counseling sessions, or up to 40 group counseling sessions a year.
• You pay some of the cost (your copayment) of your counseling sessions. For example, you might pay a $25 copayment for each individual counseling session and a $15 copayment for a group session.
• These copayments may be higher than those you make when you visit your primary care doctor.
• Some states have laws saying that health plans can ' t put limits on mental health care that are different from the limits they put on other kinds of care. Check with your state insurance department or visit www.healthinsuranceinfo.net to learn about your state ' s laws.

Care in a Hospital

Most plans limit the number of days they pay for your mental health or substance abuse treatment in a hospital. This is called inpatient care.

• Most managed care plans cover up to 30 days in the hospital for mental health or substance abuse treatment.
• You usually must be referred or admitted to the hospital by your mental health doctor or counselor.
• Talk to your plan ' s member services department and read your plan materials to learn what your plan will pay for treatment in the hospital and for how long. Find out if your plan will pay for an alternative to inpatient care, such as intensive outpatient care or partial hospitalization. This type of care may cost less and allow you to get longer treatment.

AARP Resources

Depression:  Myths, Causes, and Types of Depressive Disorders
Depression is more than feeling sad and down in the dumps, but it can be successfully treated.

Helping Him
What to do if you think someone you know is depressed.

Calling it Quits
Drug abusers aren’t all young; there’s a hidden epidemic of older abusers.

Additional Resources

Healthinsuranceinfo.net
Read  the state-specific “A Consumer Guide for Getting and Keeping Health Insurance” for your state.

“The Consumer’s Right to Health Care: How to Overturn Managed Care Treatment Denials”
National Mental Health Association lists the steps to challenging a managed care plan decision.

Questions to Ask Your Employer’s Benefits Manager
American Psychological Association suggests a series of questions to ask your employer or health plan about your mental health and substance abuse benefits.