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Understanding Your Mental Health Insurance

It is important to understand the options for funding counseling and psychological services prior to your first session at Bethlehem Counseling Associates. The following information should assist you in determining the method you would prefer to use for payment.

Standard Fees in Direct Payment Plans:

The standard fees for services at Bethlehem Counseling Associates are as follows:

Following the payment of the standard fee, each client or responsible party receives a receipt that includes all the necessary information for submitting the receipt to your insurance company for reimbursement. BCA does not accept payment from indemnity insurance plans. For clients with indemnity plans, it is their responsibility to make direct payment and submit the receipts to the insurance company.

What Insurance Companies Does BCA Accept?

BCA providers are members of most insurance panels; however, it is important for you to call your specific insurance company and ask about mental health coverage or behavioral health coverage. BCA deals with approximately 75 to 100 different groups who offer funding for mental health services. Presently, the mental health coverage most frequently provided for clients at BCA include:

• Highmark Blue Shield and associated Blue Shield companies
• Capital Advantage Insurance or better known as Capital Blue Cross
• Magellan Behavioral Health
• United Behavioral Health
• Horizon BCBS of NJ
• Aetna
• Medicare
• Tricare
• Spectrum
• Personal Choice
• Oxford

When you call BCA to do a phone intake interview, the office staff will ask you for your insurance information. Once it is determined that you have an insurance program that covers mental health and BCA is a provider, then an appointment will be established. BCA staff will not schedule an appointment until it is determined that you have appropriate insurance coverage or you decide to pay without utilizing your insurance.

It is one of our goals at BCA to ensure that our clients receive high-quality mental health care. We realize that “affordability” is a real issue for most of us. We hope the information helps you better understand insurance and the funding options available to you.

Sliding Scale Payment Plan:

If you feel you cannot afford the standard fees at BCA, the sliding scale payment plan offers you a reduced fee based on your annual gross household income and number of dependants for the income. Clients choosing this option must provide the front page of their IRS form and sign an agreement that they are either ineligible for insurance reimbursement or that they do not choose to use insurance reimbursement for payment.

Insurance Payments:

There are two types of insurance plans that will pay all or part of the fees for services directly to BCA. Preferred Provider Organizations (PPO) pay providers in their specific network directly at a contracted rate that has been established with the provider. Health Maintenance Organizations (HMO) work just like a PPO but also require providers to send in treatment plans to “precertify” the requested services. The front desk staff at BCA will help you determine if your insurance is a PPO or HMO plan that can be used at BCA.

Determining a Treatment Plan:

In HMO plans, a case worker at the insurance company will have the final authority to determine the number of sessions you are allowed and the ability to continue services with your counselor. It is a problem to have someone outside the client-counselor relationship determine the quality of care. If you use HMO insurance plans, it is critical to be aware of the importance of the insurance reviewer in determining your treatment plan.

In-Network Providers:

PPO and HMO plans contract with certain providers to be designated as “in-network providers.” Counselors may be selected to join a network because they accept low fees, because they have a particular specialty, or because they applied to the network when it was being created. It cannot be assumed that a provider of service is in-network or out-of-network simply because of their quality of care standards.

Primary Care Physicians (PCP):

In most HMO plans you must contact your PCP to receive permission to obtain mental health services. The PCP can provide you with a list of counselors who are in-network.

Precertification:

In most HMO plans, the insurance company or the PCP must precertify mental health services before you can go to the first counseling session. In most cases, reimbursement will be denied if services are not precertified.

Premium:

The premium is the fee charged by insurance companies to purchase their insurance coverage. Premiums are often shared between employers and employees with the amount of the employee share having increased over the past decade.

Responsible Party:

This term refers to the person responsible for payment when a client receives counseling services. Although the most common case is the situation where the client is the responsible party, there may be other situations. For example, if a child is the client, the parents may be the responsible party.

Three Basic Types of Insurance Plans for Mental Health Benefits

In planning for payment you should first determine which of the three basic types of insurance plans you currently have. Many of the questions you have will be answered by determining the type of plan you have and verifying your mental health benefit with the Employee Benefits Manager at your workplace or making direct contact with the insurance plan’s Customer Service Representative.

Indemnity Plan:

Indemnity plans allow for the insurance payment to go directly to the client or the responsible party for the client. Consequently, the client or responsible party pays in full for the mental health services that are received. The provider of the services provides a receipt that can be submitted to the insurance plan, the client or responsible party then submits the receipt and receives reimbursement from the insurer. With Indemnity Plans there is often a deductible amount that must be paid by the client or responsible party before reimbursement is offered. Indemnity Plans reimburse on Standard Fee for services, allow clients to choose their own counselor, and allow the counselor to determine how many sessions are necessary.

Preferred Provider Organizations (PPO):

PPO plans establish contracts with a group of counselors who are noted as “in-network providers.” The contracts set the fees that in-network providers are allowed to bill. The fees are only paid to the provider and cannot be paid to the client or responsible party. The cost to the client or responsible party may include a deductible and/or co-pay. If the client or responsible party selects an out-of-network provider, the plan may be the same as an Indemnity Plan.

Health Maintenance Organizations:

HMO plans operate in a similar manner to PPO plans, however, HMO plans have three unique characteristics. First, HMO plans require that all mental health services are precerted by the primary care physician (PCP). Second, HMO plans require that the in-network counselor submit treatment plans to a designated person at the insurance company. The person at the insurance company then determines the necessity for services based on the treatment plans. Third, there is no benefit provided to the client or responsible party if an out-of-network counselor is selected. Like PPO plans, HMO contracts set the fees for in-network providers and the fees are only paid to the provider of services. These plans seldom have a deductible but often require a co-pay. HMO plans generally have lower premiums then Indemnity and PPO plans.

Click here to see our Mental Health Insurance Glossary of Terms