Deciphering individual health insurance plans
January 17, 2013 12:57 PM   Subscribe

I'm trying to figure out the best choice for individual health insurance for myself, and I'd like to have it pay for my currently-out-of-pocket therapy, but I have questions about how this works. Does therapy count as an "office visit"? Do I actually want insurance to cover therapy? (I'm in the US.)

I'm currently insured but on a plan that isn't helpful for me. I'm trying to decide between two PPO plan types from Anthem Blue Cross California (assume the annual deductibles and maximum out-of-pocket costs are similar):

Plan A: Premium is $100. Office visits are $30 per visit, 3 visits per year (additional visits covered at 30% after annual deductible).

Plan B: Premium is $130. Office visits are $30 per visit for as many as you like.

(I looked at HMO and HSA options and I don't want them.)

My psychologist is $150/session, and I'm currently doing weekly sessions, paying out of pocket. The only type of insurance he takes is Blue Cross. I like him and we're making progress, so I don't want to switch. I can afford this, but it'd be great if insurance paid for it instead. I haven't been able to find any details about talk therapy coverage in the Blue Cross brochures or website.

Does therapy count as an "office visit"? If therapy counts as an "office visit", plan B is better. If therapy doesn't count as an "office visit", plan A is better. But would insurance even cover therapy since I don't have a formally diagnosed disorder, just general issues? And do I want insurance to cover therapy at all, if I can afford to pay for it out-of-pocket? I don't have any diagnosed pre-existing conditions right now, and I'd really like to keep that lucky status for as long as possible. If a couple thousand dollars of out-of-pocket spending right now prevents having serious insurance problems in the future, that seems worthwhile. But if I can safely use insurance to pay that couple thousand dollars, that would be nice.
posted by mysh to Health & Fitness (10 answers total)
I have no conditions diagnosed, mentally or otherwise; my insurance company, a Blue Cross organization, clearly specified among my benefits a rate for mental health coverage, which paid for most of the costs of talk therapy after deductible. If you can't find the information, I'd strongly suggest just calling them and asking a human being - you've got a pretty straightforward question that they'll definitely be able to answer.
posted by Tomorrowful at 1:02 PM on January 17, 2013

First off, whatever you are in therapy for will be a pre-existing condition, and I don't think the ObamaCare prohibition on pre-existing conditions kicks in until next year. So you aren't going to get the therapy covered anyway.
posted by COD at 1:03 PM on January 17, 2013

Does therapy count as an "office visit"?

Most insurance companies have a completely different category for mental health stuff, and that category defines if and how therapy visits are covered. The brochure and website are, practically, useless. You need to either sit down with their salespeople, or sit down with an independent broker and go over the particulars. Buying insurance based on brochures is a very bad idea, because the plans are always more complicated than the advertising materials, and, as per usual, the devil is in the details.
posted by griphus at 1:06 PM on January 17, 2013

You definitely need to know the full plan details before buying.

Adding on to griphus's point; in the section which mentions if there is mental health coverage, there will a maximum yearly cap (I can't see it being higher than $500 for <$150/month plan), and it's usually a %age of standard rates, like dentistry. I.E. 50-80% to a yearly max of $500. If your p-doc charges $200, when average is $100 than you get reimbursed for 50%-80% of the $100. Often the mental health provider will require you to pay in full, and you submit to your insurer for reimbursement.

Few plans will allow pretty much anyone (therapists, counsellors, life coaches, etc), others may limit to one or more types of p-docs (psychologists or psychiatrists).

If it doesn't specifically mention mental health coverage, it's not included.
posted by nobeagle at 1:42 PM on January 17, 2013

My health coverage lists a maximum of 20 visits per year under mental health coverage. And that's only covered after deductible. There should be a mental health system under the list of covered benefits.
posted by azpenguin at 2:01 PM on January 17, 2013

Response by poster: When I tried calling for details about these plans, they asked for my name and date of birth before providing information, so I hesitated since I don't want asking about this to be associated with my future application. Should I not be worried about that?

COD, I figured that since it's out-of-pocket and for non-serious issues, I can decline to inform Blue Cross about it when I apply. Am I wrong on this?

azpenguin, do you have a Blue Cross plan or a different kind of plan? In the brochures, I saw listed under "Mental or Nervous Disorders or Substance Abuse" 20 visits per calendar year for plan A and 48 visits for plan B, but I don't know if that covers minor problems that aren't official disorders.

If these plans would only cover $500 a year of therapy or only cover it after the deductible, it'd be worthwhile for me to keep paying for it out of pocket. If they'd cover half of it, then the value would depend on whether it would cause problems for me in the future.
posted by mysh at 2:52 PM on January 17, 2013

We have an Anthem PPO plan (though, we're in Indiana). Anthem considers mental health services (i.e. therapy) as a specialist visit. You will pay a $40 co-pay for a visit to your therapist, and not the standard $30 co-pay.

Generally, Anthem does not limit you to a fixed number of visits to the therapist. However, your therapist will probably have to contact Anthem from time-to-time to get re-authorized for another block of visits.

Anthem should be able to tell you specifically what your coverages and costs will be.
posted by Thorzdad at 2:58 PM on January 17, 2013

I suppose you could call and give a fake name and birthdate, then give your real name when you actually apply.
If insurance is going to pay for it you have to have a diagnosis. Their perspective is that they pay to treat a diagnosed illness. Alot of therapists would use adjustment disorder to cover general life problems.
If you have a diagnosis then your next insurance may be harder to find. And perhaps what jobs you can have in the future will be affected, and perhaps if you can own a gun or not. And whether the ER doctor will give you pain medication. And if your family doctor will refer you for specialist care or tell you its all in your head. Lots to think about, everyone weighs the risks differently....
posted by SyraCarol at 6:01 PM on January 17, 2013

//COD, I figured that since it's out-of-pocket and for non-serious issues, I can decline to inform Blue Cross about it when I apply. Am I wrong on this?//

BCBS will expect you to disclose every single drug you have taken and every single medical issue that you have been diagnosed with, or would have been diagnosed with had you gone to a doctor, for your entire life. I am not exaggerating. I've been through the application process several times. I would rather have a root canal than apply for individual medical insurance. The fact that it is out of pocket does not matter. There is even a clause that gives then the right to deny you for stuff they think you should have have known about, even if you never went to a doctor. Failure to disclose will give them cause to cancel your policy just when you need it most.
posted by COD at 9:27 AM on January 19, 2013

Response by poster: Just a belated followup - I filled out the application very completely, and it was accepted, with normal benefits and no special exceptions for therapy coverage. Success. COD, thanks for the practical advice, and thanks to everyone else too!
posted by mysh at 11:32 AM on May 16, 2013

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