The Health Insurance Maze
If you have private health insurance through an employer, or you've purchased private insurance independently, your insurer's benefits information officer is the first person to call or visit in person. Before you ask about specific coverage for OCD, get a general (written and verbal) description of covered items and exclusions in your plan. In this conversation, the most important question to ask is whether your plan offers any mental health coverage.
Called either Mental Health or Behavioral Health Services, you will usually find substance abuse treatment and/or other mental healthcare services grouped in the same category. Covered services often include mental health assessment and outpatient care including individual therapy and medication management. Some insurers offer coverage for mental health services and/or substance abuse treatments; some only cover substance abuse if it co-occurs with mental illness. If you plan to use these benefits through your insurance plan or HMO, you may be required to get a referral from your primary care doctor (or pediatrician) before you can receive services.
The following are common types of managed care health insurance plans, which may cover your child's assessment and treatment for OCD as well as other common childhood anxiety disorders such as ADHD.
HMO, Health Maintenance Organization: A plan that provides a selected set of healthcare services from doctors or healthcare providers within its network.
FFS, Fee-for-Service: A health plan in which you may use any healthcare provider you choose. If there is a difference between what the provider charges and the health plan pays, you have to pay the difference.
PPOs, Preferred Provider Organizations: These 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.
Health insurance policies are called a maze for a reason. They often use unusual vocabulary and employ a lot of language for the purpose of legal indemnification. Whenever you call an insurer's benefits office, note the date and the name of the person you are speaking to. Keep a log of these conversations in the event you need to make an appeal or refer to past interactions.
