Is there a way to get more than the approved

Discussion in 'General Parenting' started by busywend, May 6, 2004.

  1. busywend

    busywend Well-Known Member Staff Member

    # of visits for psychiatrist? I believe my Insurance covers 20 visits per year (well 50% - I have to pay $54 a visit :eek: ) but is there a way to get the insurance company to approve more?
     
  2. bigblueagain

    bigblueagain New Member

    that is pretty typical coverage amounts Busywend. Mental health coverage is usually considered an "added" benefit". that is most employers feel like it is a bonus benefit. They also tend to hedge that there won't be as many people using mental health benefits, so scrimping on them is not such a big deal.
    I don't know if you are aware that there has been a huge movement to move mental health benefits to be considered like medical, ie, no limits on office visits, copays that are the same as medical etc. It is called the Mental Health Parity bill, and I have not checked the progress on it lately, but is moving very slowly. Some states have tried to get around it by passing state laws, but most don't even consider it. And those states that did pass some measure to equalize the benefits usually had a loophole attached that could allow employers to opt out of the coverage altogether.
    But back to your original question....what type of coverage do you have? HMO, PPO, or indemnity(like the old BC/BS plans where you could go anywhere or any amount of times.). Also is your coverage provided by your employer and do you know if they are self insured? Let me know and I will check back with you on it. BLUE
     
  3. busywend

    busywend Well-Known Member Staff Member

    difficult child is on biodad's policy. It is Preferred Care through his employer.

    I have heard of places that bill you on a sliding scale - does the insurance still pay a portion for those places?
     
  4. bigblueagain

    bigblueagain New Member

    the carrier would not have to continue to pay if you have maxed out your benefits for the calendar year. If the preferred care is thru a self insured employer group the employer could be approached to make an exception and allow continuing coverage. That would have to go thru their human resources department as a benefit appeal. IF is not self insured, the employer could still ask on your behalf, but usually does not wish to get involved in the middle. This is because the risk is on the carrier, not the employer, and the employer's covered lives basically get only what the employer has set up to pay for. It is sort of like a savings account if you want to think of it in that way. Your employer if fully insured by a carrier pays a certain fixed amount to that carrier to pay what is forecasted claims for a certain time period. These are based on prior "experience" of the group, meaning the amount of utilization the employees have done previously. If paid claims go over the set amount, the employer usually does have some responsibility for covering them, but the insurer has the most responsibility. Hence the reason the employer does not like to get too involved. A self insured employer has more say over how the money is spent, as they are taking the risk themselves.
    One thing I would suggest is to ask your mental health provider to write a letter of appeal on your behalf. You can call the preferred care carrier, ( I am assuming is BC/BS if is called "preferred care"), and ask for the steps in an appeal of benefits. There is some medical necessity to your appeal, but when a benefit is maxed it usually doesn't matter if it is medically necessary or not.....the benefit just isn't there. Let me check your state regs too on mental health coverage.......but I really need to know if your employer is self or fully insured, as self insured employers are exempt from the regs. BLUE
     
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