SAMHSA Guide on Health Insurance and the Provision of Mental Health and Substance Abuse Services, Page 1

Because it’s provided directly by the US government’s National Mental Health Information Center, if you’re in the US, this guide may be just the thing to answer your questions about health insurance and the provision of mental health services and substance abuse services.

How can I get services? Whom should I contact?

Call your insurance plan, or your company’s benefits administrator, and ask for a verbal and written description of what coverage is provided for behavioral health treatments. Many insurers offer coverage for mental health (MH) services and/or substance abuse (SA) treatments; some only cover substance abuse if it co-occurs with mental illness. If you plan to use MH or SA benefits through your insurance plan, you may be required to get a referral from your regular doctor before you can receive services.

Additionally, your employer may offer an employee assistance program, or EAP. An EAP is a resource provided either as part of, or separate from, employer-sponsored health plans. Usually EAP visits are free, but the number of visits may be limited. Preventive care measures such as health screenings, mental health or substance abuse screening, and/or wellness activities will be provided. An EAP may not include all services and programs, but many provide aid to employees and their families for substance abuse, stress, depression, and other mental health issues. EAP visits are confidential; information discussed in these visits will not be shared with your employer.

If you do not have access to an EAP or employer-sponsored health insurance, you may qualify for Medicare or Medicaid services. To determine your eligibility for these and other government programs, and to determine what kinds of coverage are provided, contact the Centers for Medicare and Medicaid Services (CMS), www.cms.gov, at 1-877-267-2323 (TDD: 1-866-226-1819) and your State’s department of insurance. On the web, you can find contact information for your State’s department of insurance at naic.org. You can also find contact information for your state’s mental health program from the National Association of State Mental Health Program Directors at nasmhpd.org.

Your State mental health agency will be helpful in telling you how mental health services in your State are funded. In publicly funded mental health centers, such as those run by State, city or county governments, the cost of many services is calculated according to what you can afford to pay. So, if you have a lack of funds, services are still provided. This is called a sliding-scale, or sliding-fee, basis of payment. In addition, States, which often work with Federal programs, such as Medicaid, provide financial assistance to eligible individuals or families. Information about medical and health care assistance is available at your county/city social services departments, health and human services department, or Social Security office.

What can I expect from my insurance plan?

Insurance coverage for mental health (MH) and substance abuse (SA) benefits differs among plans, employers, and States. State laws may require insurers to provide a standard, minimal offering of MH and/or SA benefits although insurers are free to provide additional coverage. In general, mental health benefits are not as extensive as medical/surgical benefits and will require higher deductibles and co-payments in addition to any regular, fixed payments.

The following are common types of managed care health insurance plans:

HMO, Health Maintenance Organization

A plan that provides a selected set of health care services from doctors or health care providers within its network. These plans highlight preventive services.

FFS, Fee-for-Service

A health plan in which consumers may use any health care provider they choose. Providers are paid a fee for each health care service performed; the plan will either pay the doctors directly or will reimburse you for the cost of the service after you have filed an insurance claim. Fee-for-service plans are a type of indemnity insurance.

  1. PPOs, Preferred Provider Organizations, are sometimes referred to as fee-for-service plans. PPOs differ from FFS plans in that they use a network of providers and usually charge lower fees.

POS, Point-of-Service plan

A plan that operates under a FFS plan and/or a HMO.

  1. Under a HMO, a POS allows consumers to visit health care providers outside the HMO’s network as well as providers inside the network. Using a provider outside the network requires will result in higher copayments and deductibles, and you may have to file a claim for reimbursement.
  2. b. Under a FFS plan, consumers can visit the provider of their choice. There may or may not be a network of providers – if there is a network, consumers are usually offered lower copayments and/or no deductible to see a provider within the network.

How can I enhance my insurance?

You are eligible for a Medical Savings Account, or MSA, if you work for a business with 50 or less employees and have high-deductible employer-sponsored health insurance. Self-employed individuals are also eligible for MSAs if they have a high-deductible insurance plan. MSAs are accounts that can be used along with your health insurance plan only if your plan has a high deductible and is your only health insurance plan. “High” is defined as a $1,600 deductible or more annually per individual, and $3,200 or more annually per family. Before reaching this deductible, all medical costs, except for insurance premiums, can be paid from the consumer’s MSA (insurance premiums can be paid by the MSA if the consumer is between jobs and not collecting state or federal unemployment benefits). Contributions to the MSA are tax-exempt and the consumer gets to keep any account money that is not spent. Money in the MSA can be withdrawn for non-medical expenses, but those withdrawals are subject to a 15 percent tax.

A FSA, or Flexible Spending Account, is similar to an MSA, but FSAs do not have to be used with high-deductible insurance plans. These accounts are also open to anyone whose employer offers them. However, with a FSA, consumers do not get to keep their unspent account money and money can not be withdrawn for non-medical expenditures.

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