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Seven Questions To Ask Your Employer's Benefits Manager
You often don't discover what your managed care plan or health insurance plan
covers until you need services. This is especially true for mental health care
and substance abuse treatment.
You can find out what is covered -- and not covered -- by asking the benefits
manager in the human resources or personnel department where you work. Knowing
what to ask can be difficult.
The following list of questions and guidance may be helpful:
1) Benefits.
If you have not already received information about your health plan, ask your
benefits manager for a copy of your health plan benefits; you have a right to
have one of your own to keep. Does this document describe what mental health
care and substance abuse treatment benefits you are entitled to? Does it explain
how to get services and how to appeal coverage decisions you do not agree with?
Does it explain what your financial responsibilities are? Is the coverage equal
to
that offered for other illnesses?
2) Professional Expertise.
Ask your benefits manager which mental health professionals are covered by your
plan. Does the plan cover a full range of mental health professionals? What is
their training and experience? Are they licensed or certified? What kinds of
treatments are available? What treatments are excluded?
3) Contractual Limitations.
Ask if there are any financial agreements or arrangements that the professional
has had to make with a third-party payer or insurer that could interfere with or
influence their treatment decisions.
Is the professional constrained from telling you about all treatment options
even those not covered in the plan? Is the professional in danger of being
discharged from the plan for advocating for your optimal care? Does the plan pay
the professional the same amount regardless of treatment prescribed?
Does the plan reward the professional for limiting services?
4) Appeals and Grievances.
If you have concerns about the certification or authorization of treatment
decisions made by the payer or insurance company, ask how you can appeal them to
the payer, your employer or the purchasing agent, or to outside regulatory
agencies. Ask what methods you can use to complain if you don't agree with the
care provided by the professional. You have the right to complain to regulatory
boards and/or
professional associations which have grievance processes, and you have the right
to air your complaints to your union, your state and federal legislators and to
the media.
5) Confidentiality.
Find out if the information to be disclosed to the payer would be anything other
than diagnosis, prognosis, type of treatment, time and length of treatment and
cost. Will the organizations receiving this information keep it as confidential
as the mental health professional? How will they protect it?
Are there penalties for disclosing information improperly?
If your information is transmitted, stored or used for any purpose as data, will
information that identifies you be removed to protect your privacy? Will the
information be transferred to others or sold?
6) Choice.
Ask if you are able to choose any licensed/certified professional for your
mental health care services. What professionals are covered and what are their
credentials? What if you choose a licensed professional not usually covered by
the plan?
7) Treatment decisions.
Is anyone besides your professional involved in your treatment decisions? If so,
do they have the same training and experience as your treating professional? Do
they have a financial interest in the decisions they make?
These questions are based on a "Bill of Rights" developed by nine major mental
health professional organizations to protect individuals seeking mental health
treatment.
Wilmes-Reitz Psychological
23945 Calabasas Rd., Suite 202
Calabasas, California 91302
(818) 591-8270
wrpsych@aol.com
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