California Psychiatric Association
What Should You Look For In A Health Plan?
Questions and Answers

HOW DO I KNOW WHAT IS COVERED BY MY PLAN?

When you initially enroll, carefully read the certificates of enrollment or plan prospectus. Most plans have a coordinator assigned to each of their enrollees. If you don't understand the coverage or you have specific questions, contact the coordinator. In many instances, the office staff of your physician or other therapist will be able to help with questions in regard to the specific conditions and benefits of your plan.

DO I HAVE A CHOICE OF THE MENTAL HEALTH PROVIDER I SEE FOR EVALUATION OR TREATMENT?

In many plans you will be able to see only "preferred providers" with whom your plan contracts. * This contractual relationship between the plan and the treating professional may alter the provider's role from serving exclusively as agent for the patient's welfare to balancing the patient's needs against the need for cost control. You need to keep this in mind, particularly when you are initially seen.

*Some plans offer an alternative arrangement called "point of service." Under this option, your plan allows you to see any physician or other therapist you choose, but at a higher cost than if you were treated by a provider on the plan's panel. This provides you with the freedom to see whom you prefer; however, if you choose a "preferred provider" your cost will be lower.

WHOM DO I SEE FIRST?

Your plan will provide you with a list of providers, most of whom will serve as "gatekeepers." In order to receive medical and/or mental health services, the prior approval of the gatekeeper is required in private medical managed care plans. This will entail a visit to a primary care physician (a family practitioner, internist or pediatrician), or, in the case of mental health services, may require telephone contact with a non- physician mental health practitioner (clinical social worker, marriage and family counselor, psychiatric nurse, or clinical psychologist). In a public sector mental health managed care plan, this almost always will be a visit to a non-physician mental health practitioner.

IS THE "GATEKEEPER" ALWAYS QUALIFIED TO ASSURE THAT I HAVE HAD AN APPROPRIATE EVALUATION AND THAT I AM GETTING APPROPRIATE TREATMENT?

In many cases yes. This will depend to a large degree on the training and background of the gatekeeper and the complexity of the problem. The more comprehensive the training of the gatekeeper, the more likely your care will be appropriate. If the gatekeeper is conscientious and ethical, he or she will recognize when you need more expert evaluation or treatment and make a referral to a specialist.

You must keep in mind, however, the contractual relationship between the gatekeeper and your insurance plan. Some plans incorporate financial incentives in their agreements with physicians in an attempt to influence the frequency with which gatekeepers refer patients, order tests or procedures and admit patients to a hospital. Other managed care plans may financially penalize physicians for making specialty referrals.

Your physician or other treating professional should be willing to describe to you the terms under which he or she is treating you, including the financial incentives and restrictions on referrals.

HOW CAN I BE ASSURED THAT THE GATEKEEPER HAS THE RIGHT TRAINING AND BACKGROUND FOR MY PROBLEM?

Don't be afraid to ask your physician or other therapist about his or her training and background! All physicians have had some training in psychiatry; however, with the exception of psychiatrists, this is usually limited. Non-medical mental health practitioners have both training and experience in the non-medical assessment and non- medical treatment of mental disorders. This, however, varies greatly with the discipline.

WHAT HAPPENS IF THE INITIAL DIAGNOSIS OR PLAN OF TREATMENT ISN'T APPROPRIATE?

Some plans, particularly in the public sector, may have built-in quality control mechanisms that will identify a missed diagnosis or inappropriate treatment plan. Ask if your plan has such a mechanism or if it offers the possibility of a second opinion. This is particularly important in mental health treatment. Delay in appropriate treatment can cause further deterioration and significantly complicate later recovery.

Recent scientific advances in the treatment of many disorders, including mood and panic disorders, obsessive-compulsive disorder, schizophrenia, phobias, substances abuse, attention deficit disorder and certain childhood emotional disorders, have provided a variety of new approaches both in the area of medical psychotherapy and psychopharmacology. When introduced in a timely way, these treatments can greatly reduce needless suffering and disrupted interpersonal relationships. Therefore, it is very important that the correct treatment be started early.

HOW CAN I BE SURE THAT MY EMOTIONAL PROBLEM ISN'T BEING CAUSED BY AN UNDERLYING PHYSICAL PROBLEM?

You can't be absolutely certain without a good medical evaluation. There are a number of illnesses such as thyroid disease, certain disorders of the adrenal glands, diabetes, some neurological conditions, autoimmune disease, and several others that can be mistaken for psychiatric disorders. Your primary care physician has both the training and the experience to provide a thorough examination in this regard. If the primary care physician finds there is an underlying medical condition, he or she will initiate treatment. If the physician finds no such readily-identifiable condition, he or she will frequently refer you to a psychiatrist.

If you are initially seen by a non-medical therapist, you can only be assured that there is not an underlying medical condition causing your emotional problem if you have had a thorough medical evaluation by either a psychiatrist or primary care physician.

WHAT IF I THINK MY SITUATION MAY REQUIRE MEDICATION?

General practitioners, internists and pediatricians can all prescribe psychoactive medications. Their experience in this area, however, is limited. This is particularly true with the newer psychotherapeutic agents or with more complicated problems. More importantly, some studies have shown that a combination of medication and psychotherapy is more effective than just medication alone. Primary care physicians are not trained to perform psychotherapy. In this situation, referral to a psychiatrist is indicated.

As can be seen from the accompanying chart, clinical social workers, marriage and family counselors and clinical psychologists do not have the training or the legal authority to prescribe medication. Referral to a psychiatrist is necessary to at least ascertain whether medication would be helpful. If it is indicated, the psychiatrist can provide it to you. If you are seeing a non-medical practitioner and feel you may need medication, don't hesitate to raise the issue with him or her and ask for a referral to a psychiatrist.

WHAT IF THE TREATMENT APPROACH AGREED UPON BY MY PROVIDER AND MYSELF IS DENIED BY MY PLAN?

All plans have a process by which you and your physician or other therapist may appeal a denial of treatment. Unfortunately this takes time. In some cases, treatment is allowed to proceed until the appeal is resolved. It is the responsibility of your physician, mental health therapist or psychiatrist to submit the appropriate justification and plan for treatment in a timely manner. This also holds true for appeals. The conscientious physician or therapist will continue to appeal to the highest authority in your plan if he or she feels that continued treatment is clinically justified.

WHAT IF MY TREATMENT PLAN IS ULTIMATELY DENIED DESPITE THE APPEALS OF MY PROVIDER?

Under these circumstances, your physician or other therapist will no longer be reimbursed by your plan for your care. You and your care giver may be able to arrange some type of limited reimbursement program so that treatment can continue. In cases where you become financially liable for treatment that has already been provided and payment is retroactively denied by your plan, you may be able to file suit or initiate an arbitration proceeding against your plan to recover the cost of your treatment. However, this does not necessarily mean that you will be successful in such a suit or arbitration.

IS WHAT I DO OR SAY IN TREATMENT CONFIDENTIAL?

With certain exceptions, communication between the patient and his or her physician or other therapist is privileged and cannot be discussed with anyone outside that relationship, including relatives and friends, without the written permission of the patient. In California, however, there are some exceptions to this.

State law requires that providers of health services notify Child Protective Services if there is an indication of child abuse, molestation or neglect. If there is evidence of imminent physical danger to another specified individual, mental health practitioners are required to notify that person and local law enforcement. If a patient has a positive blood test for AIDS and is acting in a sexually irresponsible manner, mental health providers are permitted to notify an endangered spouse or partner. If there is evidence of physical abuse or exploitation of an elderly or dependent adult, providers are required to notify Adult Protective Services.

At the time you enroll in an insurance plan you almost always sign a release so that the plan may obtain information about your treatment from your provider, including any mental health provider, to justify reimbursement for your treatment. Frequently you sign this release long before you seek mental health services. The amount of information required by different plans varies. Discuss this issue with your provider. The physician or other mental health provider frequently has some latitude in what information is released and will usually try to conform to your wishes where possible.

WHAT DO I DO IF I AM DISSATISFIED WITH SOME ASPECT OF MY PLAN?

Contact the health plan coordinator to whom you are assigned and attempt to work it out. If the problem is not resolved, go to the insurance carrier representative. If there is still no resolution, many plans have a binding arbitration agreement to which you can ultimately appeal.