Consumer Guide

How to access Behavioral Health Treatment through Your Health Insurance Plan

We created this Consumer guide to help you make good choices about getting the care you need for you and your family. On the back of this guide we’ve provided definitions of words that health insurance plans use. These definitions should help you understand this process.

• Know Your Health Insurance Plan
• It is important to know what services your health insurance plan covers. In order to gain more information, please contact your health insurance plan to verify your coverage. Information about your specific health insurance plan’s coverage is listed in your policy or certificate of coverage. In addition, your health insurance carrier should provide a Summary of Benefits and Coverage (SBC) that lists both coverage and cost shares in an easy to read format.

When looking for information about your health insurance plan, here are some important questions you should ask:

• What is the difference between in-network and out-of-network, and why does it matter?
  • In-network providers have agreed to a rate with your health insurance plan which will not exceed the cost of your copay, deductible, or coinsurance amounts.
  • Out-of-network providers have not agreed on a rate with the health insurance plan. This type of provider can bill you for an amount beyond what your health insurance plan pays.
• Does your health insurance plan cover out-of-network providers?
• What are the copays if you use an out-of-network provider?
• What services require prior authorization under your health insurance plan?
  • Prior authorization is when the health insurance plan requires you and your Primary Care Provider to seek medical necessity approval before receiving services.
• What if there are no in network options that fit your needs in your health insurance plan?
• Seek “Medical Necessity” Approval
• Health insurance carriers approve services they determine are “medically necessary”. Some medical services require prior-authorization, this means that the health insurance plan must approve treatment before the patients receives services. It is important that your Primary Care Provider (PCP) is involved in this process.
• It is important to note that if you are denied service, you have a right to appeal the denial.
• For more information on how to appeal denials you should contact your health insurance plan.

• Determine Your Out-of-Pocket Expenses

 

Before beginning treatment with a provider that is not covered by your plan, it is important to understand all of your out-of-pocket expenses.

• You should call your health insurance plan to be sure that your plan offers the option to use out-of-network providers.
• It is important to remember that you are responsible to pay for any charges that exceed the allowed amount as set by your health insurance plan.

• Make Informed Decisions

 

As a consumer it is important to make sure you have all the facts and Information before you make any choices on behavioral health care.

Important Tips for Consumers

• Start with your primary care physician and ask them to recommend other providers within the plan’s network.

• Research the providers in your area with your health insurer.

• Consider using an in-network provider. It provides the most consumer protection and it costs less for you.

• Have services approved in advance whenever possible. Please make a note of who you spoke to and the date and time of each call.

• Use the glossary on this page to help you understand the terms that are used by your health insurer.

• Remember, if you have any questions, call your health insurance plan.

 

 

Glossary

Coinsurance- Your share of the costs of a covered health care service, which is usually calculated as a percent.

Copay- A fixed amount you pay for a covered health care service, usually when you receive the service.

Cost Sharing- The amount you pay for health care expenses that are not covered by your health insurer including copayments, deductibles, coinsurance, and provider charges over the allowed amount.

Deductible- A set amount you have to pay every year toward your medical bills.  If you have a deductible, some health insurance plans may not start paying your medical bills until you have met your deductible.

Health Insurance Plan– An insurance company that provides health insurance coverage that pays for medical, surgical and behavioral health expenses incurred by the insured or member. The Health Insurance Plan may reimburse the insured or member for expenses incurred from illness or injury, or pay the Provider of care directly.

Medical Necessity- Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Prior-Authorization- A decision by your health insurer that a health care service is medically necessary, this means that the health insurance plan must approve treatment before the patients receives services. This is sometimes called prior authorization, prior approval or precertification.

Provider- A physician licensed to practice medicine in all its branches, licensed clinical psychologist, licensed clinical social worker, licensed clinical professional counselor, licensed marriage and family therapist, licensed speech language pathologist, or other licensed or certified professional.

 

• In-Network Provider- The facilities, health care practitioners and suppliers your health insurer has contracted with to provide health care services to you at a discounted price.
• Out-of-Network Provider- The facilities, health care practitioners and suppliers who do not have a contract with your health insurer to provide services to you. You will pay more to see an out-of-network provider.
• Primary Care Provider (PCP) – A physician, nurse practitioner, or physician’s assistant who is the first line of care for a patient. The PCP will help you get the services you need.

Type of Insurance	Phone Number	Website	By Mail
	1-800-841-2900	www.mass.gov/masshealth	TBD
	1-877-623-6765	https://www.mahealthconnector.org/ombudsman-contact-form	Health Connector Ombudsman Office PO Box 960484 Boston, MA 02109-9997
All others	Division of Insurance   (617) 521-7794	http://www.mass.gov/ocabr/docs/doi/consumer/css-complaint-form.pdf	Office of Consumer Affairs and Regulations 1000 Washington St , Ste. 810 Boston, MA 02118-6200