Paying for Care
Understanding Your Health Coverage
1) Read your policy or call your insurer for information. You must know what type of insurance you have to understand your benefits. The most common types of health coverage are:
- Group insurance: private insurance or an HMO plan provided by your employer.
- Individual insurance: private insurance or an HMO plan that you buy on your own.
- Medical Assistance, Medicaid: Health coverage provided by the state and federal government for people with low incomes.
- Medicare: Health coverage provided by the federal government for adults over 65 and people with disabilities. Your benefits depend on the type of health plan you have. Today almost all health plans in Maryland provide some mental health coverage. Your policy should tell you how many office visits and inpatient days are covered in a year. You need to know if there are rules about whom you can choose for your mental health professional. Some insurers require that you see a mental health professional in the insurer’s network. If you choose a mental health professional who is not in the network, your care may not be covered or you may have to pay more of the cost of treatment.
2) Always plan before you begin mental health treatment.
- Private insurance: HMOs often require a referral from your primary care physician. Private insurers usually require that you get permission before you seek care. This means that you must call your health plan before care begins. If you don’t, the insurer will not pay for your care.
- Medicaid and services for people with low incomes who don’t have insurance: To request public mental health services, call 1.800.888.1965 or TTY 1.800.735.2258, or call the local core service agency in your county.
- Medicare: Medicare sets a fee that it will pay for treatment. For outpatient care, Medicare pays the mental health professional one-half of the fee. You must pay the other half. You can either pay the other half of the cost yourself or the cost may be covered by Medigap insurance. Medigap insurance is a health insurance policy sold by private insurance companies. The Medigap insurance may help you lower your “out of pocket” costs. To find out about Medigap policies, call the Maryland Insurance Administration, 1.800.492.6116 ext. 2244 or 410.468.2244. If you have both Medicaid and Medicare coverage, you may be responsible for paying up to 37.5% of the fee.
- The Pro Bono Counseling Project: The Pro Bono Counseling Project offers free mental health care from licensed mental health professionals to families and to people with no insurance and low incomes. The Pro Bono Counseling Project provides counseling for:
- family and couples issues
- anxiety disorders
- problems with self-esteem and social interactions
- eating disorders
- adjustment to untreatable illness
- grief and loss
- separation and divorce
- physical and sexual abuse and other forms of violence
- The Pro Bono Counseling Project doesn’t treat patients with chronic mental illness or disorders due to drug and/or alcohol abuse. To contact the Pro Bono Counseling Project, call 410.323.5800, 301.805.8191, 1.877.323.5800, or visit them online at www.probonocounseling.org.
3) Understand the limits of your coverage.
- Managed Care: Insurers decide how much care is “medically necessary” for an illness. Care is “medically necessary” if your health will be in danger if the care is not provided. They will only pay for that level of care. If your insurer determines that the treatment you want is not “medically necessary,” you are responsible for paying for the care you receive.
- Pre-Existing Conditions: If you want private insurance and you already have an illness, insurers can sometimes delay or refuse to give you coverage for that illness. This is known as a “pre-existing condition.” For someone with a pre-existing mental illness, this means that an insurance company may offer you general health coverage but leave out or delay coverage for mental health treatment for a limited period of time. The law requires that mental health problems be covered by certain dates, no longer than two years.