Frequently Asked Questions about Mental Health Coverage

How can I get services?
What about parity?

What can I expect from my insurance plan?

Insurance coverage for mental health (MH) and substance abuse (SA) benefits differs among plans, employers, and States. State laws may require insurers to provide a standard, minimal offering of MH and/or SA benefits although insurers are free to provide additional coverage. In general, mental health benefits are not as extensive as medical/surgical benefits and will require higher deductibles and co-payments in addition to any regular, fixed payments.

The following are common types of managed care health insurance plans:

1. HMO, Health Maintenance Organization - A plan that provides a selected set of health care services from doctors or health care providers within its network. These plans highlight preventive services.
2. FFS, Fee-for-Service - A health plan in which consumers may use any health care provider they choose. Providers are paid a fee for each health care service performed; the plan will either pay the doctors directly or will reimburse you for the cost of the service after you have filed an insurance claim. Fee-for-service plans are a type of indemnity insurance.

a. PPOs, Preferred Provider Organizations, 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.

3. POS, Point-of-Service plan - A plan that operates under a FFS plan and/or a HMO.

a. Under a HMO, a POS allows consumers to visit health care providers outside the HMO’s network as well as providers inside the network. Using a provider outside the network requires will result in higher copayments and deductibles, and you may have to file a claim for reimbursement.

b. Under a FFS plan, consumers can visit the provider of their choice. There may or may not be a network of providers - if there is a network, consumers are usually offered lower copayments and/or no deductible to see a provider within the network.

Used by permission of Abuse and Mental Health Services Administration