Health insurance question (U.S., psychiatric)

My employer was recently acquired by another company and I’ve had to research their various insurance offerings. Then it turned out the one I chose is being dropped for 2007. Hence my question…

It’s about doctor’s visits to a psychiatrist every couple of months for a 15-minute medication check. It’s not a “talk therapy” appointment, it’s checking up to see how my son is doing and writing new prescriptions.

In the past, this has always been covered under the “medical outpatient” part of the insurance. However, I phoned my employer’s help line and they say that under their insurance, this is covered under “mental and nervous” provisons. What that boils down to is that their payment is a lot less when it’s considered “mental and nervous” vs. “medical.”

My question is, is it totally up to the insurer whether this kind of visit is considered to be medical? I am wondering whether they just gave me the wrong information or whether it’s really considered that differently from other insurance I’ve had in the past.

Also, are there any laws or regulations about this? (I doubt it, but it doesn’t hurt to ask.) (It’s in Massachusetts, if that matters.)

Very odd. I am in Massachusetts as well and I am in the exact same boat. The only difference may be that I actually work for the HR outsourcing company that coordinates these things. My new plan was hard to figure out as well but my company deals with all of them directly so I had ways of finding out. I concluded that my new plan treats it as a specialist visit with an increased copay.

What plan might I ask?

The insurance company I work for would cover that under mental health services, which we pay up to 20 office vists per year at the copay level. For a once a month visit, you wouldn’t see any difference on our plan regardless of how it was catergorized.

Your state laws may make a difference. There certainly are states that do not treat mental health issues equitably. They can call it anything they want to, but it is still medical. Twisting truth like that just holds back progress in getting treatment.

I wonder how they explain the similarities in medical and medicine.

There is a mental health coverage parity law in Massachusetts that forces insurance companies to provide equivalent benefits for some types of mental health treatment.

Shagnasty, I’d rather not specify the exact plan, but the medical portion is administered by Empire Blue Cross and the mental portion is administered by United Behavioral Health. The psychiatrist is considered out-of-network for United, thus the lousy coverage. And I will not consider switching doctors.

Thanks for the link, that’s very interesting. My son’s diagnosis is on their list, so presumably it should be covered under medical. So it would seem that the helpline person gave me the wrong info.

I’ve got to tell you, between the health plans changing and being dropped, and the hospital changing their billing practices and sending bills to the wrong provider, it’s been pretty ridiculous. Fortunately it’s only one visit every couple of months. But the charge per visit for this particular doctor is very high, thus my concern about getting it covered properly.

I googled around, and the Massachusetts Mental Health Parity law does not apply to all health plans. Specifically, it does not apply to self-insured plans. And I’m pretty sure my employer’s is self-insured.

From this pdf file: