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There are many facets to the world of mental health, especially when it comes to health insurance and finding adequate coverage for a variety of afflictions and disorders. We’ve put together some answers to some of the more common questions revolving around these topics for you below.

Do most health plans include mental health coverage? The answer, simply put, is yes. The vast majority of insurers and health plans cover at least a limited amount of mental health care.

According to a recent employer survey published in the journal Health Affairs:
•91 percent of small firms (10-499 employees) and 99 percent of large firms offer mental health and substance abuse coverage in their most used medical plans.
•Mental health and substance abuse coverage was included in 87 percent of indemnity plans, 88 percent of HMOs, 97 percent of Point of Service (POS) plans and 93 percent of Preferred Provider Organizations (PPOs).

It is commonly acknowledged today, in 2006, that most employees who have employer-based health insurance have access to mental health coverage, and many of the employees who don’t have coverage have simply chosen not to join an employer’s plan that includes mental health services.

Does mental health coverage cost more? Yes, this is generally the case. There are limits to mental health coverage and the reason why most employers impose limits is due to cost. Estimates vary widely of how much more mental health coverage costs. Here are some results from some studies:

•A 1998 study sponsored by National Advisory Mental Health Council (NAMHC) Parity Workgroup, a division of the federal National Institute of Mental Health, estimated that mental health services would add less than 1 percent to the cost of a health insurance policy for an HMO.

•A 1998 study by Mathematica estimated a 3.6 percent increase across all plans, with a range of 0.6 percent increase for HMOs up to a 5 percent increase for fee-for-service plans.

•A 1997 analysis by the actuarial firm Milliman & Robertson for the National Center for Policy Analysis, examining the cost of a typical mental health mandate (not specific legislation), concluded that mental health services parity legislation tends to drive up costs by 5 percent to 10 percent.

With regard to mental insurance in general, how do insurance companies treat mental illness? Insurance companies tend to be somewhat wary of mental health claims due to the increase of fraudulent claims. When Medicare looked for fraud in the community mental health centers last year, it barred 80 of them in nine states from participating in the program.

The Health Care Financing Administration (HCFA), which administers Medicare, knew something was amiss when the average yearly cost for each senior getting mental health services jumped from $1,642 in 1993 to more than $10,000 by 1997.

Medicare administrator Nancy-Ann DeParle contended at the time that 90 percent of the patients had no mental illness serious enough to qualify for special treatment.

That being said, it’s straightforward to understand why there is trepidation on the part of health insurance providers.

What mental conditions are typically covered, and not covered by health plans? Generally speaking, a health plan pays for only those services included in the plan’s list of covered services. In the case of mental health services, inpatient and outpatient treatment are most often covered by health plans.

However, there is a continuum of services between inpatient (mental health clinic) and outpatient care that effectively treat many mental disorders and are often more cost-effective than inpatient care at a mental health clinic.

These intermediate services include nonhospital residential services, partial hospitalization services, and intensive outpatient services such as case management and psychosocial rehabilitation. Psychosocial rehabilitation includes pharmacologic treatment, social skills training, and vocational rehabilitation.

Such services are covered by approximately half of employer-sponsored health plans.
Prescriptions. Are they covered? Coverage of prescription medications is also important in providing access to treatment for mental health disorders. And, on a positive note, Prescription medications are nearly always covered by health plans (U.S. Department of Labor, 1996; 1998), but this coverage is sometimes limited by formulary restrictions.

Check with your healthcare provider for the exact details on what applies to you and your family with regard to your specific circumstances.

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Choosing a health insurance plan that is best for you and your family is one of the most important decisions you’ll ever make. Choosing between health plans is not as easy as it once was. Although there is no one best plan, there are some plans that will be better than others for you and your family’s health needs. Plans differ, both in how much you have to pay and how easy it is to get the services you need. No plan will pay for all the costs associated with your medical care, some plans will cover more than others.

Most Americans have health insurance through their employers, and every year more employers offer insurance coverage by managed care organizations (MCOs). Today, Americans are in an era of managed care. It’s a new experience for most people. Managed care companies may decide what doctor you will see and when, and what treatments will be covered. It requires you to make some important decisions because not all managed care plans are the same.

In choosing a health insurance plan, you have to decide what is most important to you. All plans have tradeoffs. It is worth asking yourself a few questions such as:

• How comprehensive do you want coverage of health care services to be? • How do you feel about limits on your choice of doctors or hospitals? • How do you feel about a primary care doctor referring you to specialists for additional care? • How convenient does your care need to be? • How important is the cost of services? • How much are you willing to spend on health insurance premiums and other health care costs? • How do you feel about keeping receipts and filing claims?

You might also want to think about whether the services that a health insurance plan offers meet your needs. Call the plan for details about coverage if you have questions. It is worth considering the following:

• Life changes you may be thinking about, such as starting a family or retiring. • Chronic health conditions or disabilities that you or family members have. • If you or anyone in your family will need care for the elderly. • Care for family members who travel a lot, attend college, or spend time at two homes

Most health insurance plans provide basic medical coverage, but the details are what count. The best plan for someone else may not be the best plan for you. For each plan you are considering it pays off to find out about a range of things from physical examinations and health screenings, care by specialists and prescription drugs to vision care and dental services. It is also important to find out about the various offered services such as medical counseling as well as what is on offer.

Ask if a certain service is limited or not covered. You should find out if what is provided is what you require and if there are special programs for certain types of illness. It is also worth finding out about medicines and equipment that may be needed. Find out what types of care or services the plan will not pay for. These are usually called exclusions. Few indemnity and managed care plans cover treatments that are experimental. Ask how the plan decides what is or is not experimental. Find out what you can do if you disagree with a plan’s decision on medical care or coverage.

Finally you should think about the location of services and how far you may be prepared to go for care. On this subject you should consider whether or not the plan handles care when you are away from home.

After you review what benefits are available and decide what is important to you, you can compare plans. Many things should be considered. These include services offered, choice of providers, location, and costs. The quality of care is also a factor to think about.

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Let’s take a look at the office copay for Tonik health insurance plans. Tonik was designed to give people access to coverage for the things they use most and keep cost down. The office copay definitely fits in this category. First, what does the term copay mean.

First, what is a copay? Officially, a copay is the fixed portion of charges you pay to your provider for covered health care services in addition or separate from any deductible. For example, $20 for an office visit or $15 for a prescription drug. It is similar to coinsurance, but it is a dollar amount instead of a percentage of the charges.

The whole point of a copay is to give you a cost for certain health care services that you can count on. No hidden surprises. If an in-network doctor charges $65 and a specialist charges $95, you can the same flat copay amount and this takes some of the guesswork (and fear) out of going to a doctor when you need care. There are a few qualifications on the Tonik health plan office copays we should look at.

More detail on the Tonik office copays

The copay typically applies to the office consultation itself. It’s not uncommon for other services such as labs or simple procedures to be done during an office visit. These servcies outside the consultation would usually go towards your Tonik plan’s deductible. For example, let’s say you feel pretty lousy and go to your general practice doctor. The copay would apply for this visit. If the doctor decides to run a blood test to make sure it’s not a serious issue. You would pay the discounted rate (assuming in-network providers/ covered benefits) for this labwork subject to your deductible. Speaking to the “benefits need and keep cost low”, some Tonik insurance plans cap the number of office visit copays you have in a calendar year. After using these visits, additional visits in the same calendar year would be subject to the deductible. This number was based on what the average member needs in a typical year based on the theory that most people will find this perfectly adequate and the premium can be kept lower.

Tonik deductible and network providers

It’s important to stay within Tonik’s doctor network to get full benefit of the office copays. You will likely pay more out of pocket when using a non-network provider. Luckfully, the PPO network is pretty extensive but it’s always important to verify with your doctor of choice that they are in the Tonik PPO network.

Prescription Copays in Tonik

There is also a separate copay for generic only medications. Brand name medications are not covered with the typical Tonik health insurance plan even if there is not generic available as an alternative. The generic copay usually runs $10 and is for a $30 day supply. There is also an option of $20 copays for 60 day supplies when purchased through mail order.

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