Many Americans do not have health care insurance, and those who have mental health benefits are subject to limits on inpatient days and outpatient visits during the policy period (Table). Accordingly, it is important to review a patient’s mental health benefits before you formulate a treatment plan. Otherwise, you and your patient may find yourselves in a predicament.
If, for example, a patient with a major mental disorder requires close follow-up and you have not inquired about his or her mental health coverage, the benefits may run out before the need for monitoring ends. Abrupt transfer to another provider who is willing to accept a lower reimbursement or to a different mental health system could result in clinical decompensation.
Table
Common limitations in mental health insurance
| Mental health benefit | Coverage limitation |
|---|---|
| Outpatient care | Plans typically limit the number of outpatient visits per year, including partial hospitalization and intensive outpatient programs; copayments or coinsurance costs may be prohibitive |
| Emergency department | Copayments may be prohibitive; some states limit these amounts |
| Inpatient care | Insurance plans often limit the number of inpatient days per year; concurrent reviews by managed care organizations pressure the provider/hospital to discharge patients as soon as they no longer represent an imminent risk of harm to themselves or others |
| Psychosocial and drug rehabilitation programs | Most mental health care plans do not cover these programs |
| Pharmacy | Copayments may be prohibitive, especially if the prescriber writes numerous prescriptions when titrating a new medication |
Employ a proactive approach and inquire about your patients’ benefits during the initial evaluation.1 This information can guide the treatment plan and enable a thoughtful use of the patient’s resources. Knowing that a patient has a limited number of outpatient visits, for example, allows time for creative scheduling. You might spread outpatient visits over a longer period of time by incorporating telephone check-ins between appointments.
Other suggestions for maximizing your patient’s benefits include:
- Review pharmacy benefits. Often the greatest barrier to a drug’s bioavailability is the patient’s inability to obtain a prescribed medication. When appropriate, consider prescribing generic formulations.
- If you work part-time at a community mental health center or agency that has a sliding payment scale, suggest that a patient begin treatment with you at this location.