Managed Care And Your Mental Health: What You Need to Know About Your Managed Mental Illness Insurance Benefits
The American Psychiatric Association
1400 K Street NW
Washington, DC 20005
Introduction
In survey after survey, the American people have said they believe in equal care for mental illnesses and that every person needing psychiatric care should have access to a psychiatrist of their choice.
Unfortunately, many employers, in the name of controlling costs, only offer their employees a choice among managed care plans such as Health Maintenance Organizations and Preferred Provider Organizations. These systems may limit your choice of psychiatrist or other physician, and provide less care for mental illnesses than for other medical illnesses. Some evidence indicates that certain population groups do not do well in managed care plans.
Patients who have a choice should opt for a health insurance plan offering free choice of physician, one in which all health decisions are the responsibility of the doctor and the patient. Health care today is big business. To get the best care, patients must be informed about their own health’s needs, must understand the details of their insurance plans, and must be willing to fight for what they deserve.
Harold I. Eist, M.D., President
American Psychiatric Association 1996- I997
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Your Benefits
Don’t assume that because you or a family member do not now have a mental illness that you don’t need good mental health coverage. One in four adults will suffer from a mental illness or substance use disorder in any year. The best plans provide the same coverage for mental illness as for other medical illness such as cancer or arthritis subject to the same deductibles, co-pay amount, annual limits, and lifetime maximums. Unfortunately, most health plans discriminate by providing less care for mental illness, and by requiring you to pay more out-of-pocket for the care you do receive. Make sure the plan offers emergency care, including psychiatric emergencies, and will allow you to go to the nearest emergency facility.
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Exclusions
Read the “fine print” in your own benefit plan and ask to see the contract between the plan and the employer. If you can't understand its legalese, have your employee benefits manager or attorney explain it in straightforward language. Some plans will discriminate by strictly limiting the number of psychotherapy visits and days in the hospital, and may limit the type of medications they will provide or pay for. If you are joining the plan for the first time, make sure it will cover illnesses you suffered in the past or are currently being treated for. Many plans require a waiting period for pre-existing illnesses.
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Choosing Your Psychiatrist
The American Psychiatric Association believes that all health plans should allow you to choose your own psychiatrist, even one outside the plan, although you may be required to pay a larger portion of the cost yourself. If your psychiatrist is not a “participating physician”, a second choice is to ask whether he or she would be allowed (or would be willing) to join the plan’s panel of physicians. The third choice, and least desirable, is to negotiate a transition period with the plan in which you remain in treatment with your current psychiatrist, but eventually transfer to the care of a “participating psychiatrist.” If you must switch to a plan psychiatrist, ask your treating psychiatrist to recommend one from the plan roster. Note: Not all may be accepting new patients or be convenient to you.
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Gatekeepers
Many plans will not allow you to make an appointment directly with a psychiatrist. They require that you first be evaluated by a “gatekeeper” -- usually a family doctor, social worker, or plan service representative -- to determine whether specialist care is needed. Unfortunately, gatekeepers may not be adequately trained in the diagnosis of mental illness and may miss symptoms indicating the need for care by a psychiatrist. George Anders, in his book “Health Against Wealth” quotes the mother of a seriously ill child who was mistreated by a well-known managed care plan: "We don’t need a gatekeeper if the child is in an emergency; we need all the doors to be wide open.”
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Confidentiality
Your trust that confidential information discussed with your psychiatrist will not be shared with others is crucial to effective treatment. Ask how confidential information is protected and don't sign blanket medical record release forms; only sign time-limited requests for specific information. If the plan cannot assure you that information that would identify you will not be shared without your permission, investigate another plan, or consider contracting privately for care from a professional outside the plan who will protect your confidences.
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Quality of Care
It is nearly impossible for a consumer to judge the quality of care provided by a managed health plan, and the National Commission on Quality Assurance (NCQA) created by the managed care industry to accredit HMOs and other organizations -- at present offers limited help. The NCQA measures such things as the percentage of plan physicians who are “board certified.” It does not measure many indicators of quality -- for example, the number of participants treated for depression who resume normal functioning. To determine overall member satisfaction with the plan, request the plan’s “patient satisfaction data” from your benefits manager. However, this survey data is unreliable without knowing how the questions were asked, cannot be compared with other plans, and may not give you an indication of how seriously ill patients rate the plan. Also, ask how many member appeals were filed and how many were denied. A high denial rate may mean the plan is rationing care to save money.
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User Friendliness
Plan hospitals, clinics, and physicians should be conveniently located near your home or work place, with flexible hours of service. You should be able to get an appointment to see a psychiatrist or other professional within a reasonable period of time, and your waiting time to see the clinician once you have arrived should not be excessive. If you travel extensively make certain you are covered for care in other cities or countries.
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Open Consultation
Patients should be able to have a free and open conversation with their psychiatrist or other physician about their care. The psychiatrist should be free to tell you about all treatments that may help you; even those not covered by the plan. The physician should also be allowed to tell you about his or her financial arrangement with the plan-whether he or she benefits financially by limiting treatments and tests according to goals set by the plan. Over 95% of people responding to a recent survey said they wanted more information about financial incentives HMOs offer their physicians to reduce costs. Managed care plans can dismiss physicians who order more tests or hospital days beyond the plan’s norm. Some plans have “gag rules” prohibiting full communication between doctor and patient, or “antidisparagement” rules prohibiting any comments critical of the plan. (So far, 16 states have passed laws barring these practices.)
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When You are Dissatisfied with the Plan Offered You
Call the plan’s customer service department, and talk to your employer’s benefits manager or your union representative about your concerns. Remember: You don’t have to have mental illness in your family to be worried about the adequacy of the mental health benefit.
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When You are Dissatisfied with the Services Provided
First talk to your psychiatrist or other physician and ask him or her to appeal on your behalf. If you have been denied treatment in what you consider a life threatening situation, do not hesitate to get the care you need from outside the system, even if you have to pay the entire bill yourself. Otherwise, use the plan’s appeal process. File a formal written complaint with the plan, with a copy to your employer’s health benefits manager and to the state insurance commissioner. Write to your state and federal legislators. Seek advice from your local psychiatric society. If you have a very strong case, consider taking it to the local news media. Consider talking with an attorney about your rights. In ail cases, do everything in writing, and make as much noise as you can. In managed care, the squeaky wheel does get attention.
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For More Information About Managed Care
- American Psychiatric Association
Office of Economic Affairs
1400 K Street NW
Washington, DC 20005
For Information About Mental Illnesses
- American Psychiatric Association
Division of Public Affairs
Department HE
1400 K Street NW
Washington, DC 20005
e-mail PUBAFRS@psych.org
Or visit the APA Website http://www.psych.org
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