INSURANCE AND SELF-PAY DISCOUNTS

There are different kinds of insurance plans...HMO, PPO, POS, HSA, FSA, to name a few.  Most of these plans have a mental health and substance abuse benefit, but may limit the number of sessions in a calendar year.  In addition, some plans limit you to seeing only providers on their provider panels but may also have an out-of-network benefit with higher deductibles and copays if I am not a provider for your insurance company.

Benefits and Risks of Using Insurance

The use of insurance can be a helpful way to help cover the costs of therapy. In some situations insurance coverage might be the only way you or a member of your family can afford the care needed. Further, Darlene Morgan is a contracted provider with some insurance companies and has agreed to discounted fees with other insurance companies for which she is not a contracted provider.  In either of these instances, Darlene will file claims on your behalf and you will be responsible for payment at the time of service of any balance insurance does not cover such as deductible, copayments or coinsurance.

There are, however, some considerations you may want to keep in mind in deciding whether or not to use insurance. The most obvious concern is privacy, especially in situations where benefits may be administered through a managed care company. Managed care programs often require additional information beyond a diagnosis and sessions dates, such as presenting issues, treatment goals and strategies, and a summary of counseling to determine eligibility for benefits. With the advent of ACA (Affordable Care Act), insurance companies are requiring more information from providers to do their risk assessment and prevent fraud. Darlene is committed to preserving your privacy according to Health Insurance Privacy and Portability Act (HIPAA) and to providing insurance companies only what is required to attain coverage and comply with ACA requirements. Finally, keep in mind that use of insurance of any sort creates a record that might come into play later on when completing applications for life, health or disability insurance.

Under the Mental Health Parity Act, group insurance plans are no longer allowed to have lesser benefits for mental health or substance abuse treatment than for other medical issues.  (In the past, your plan may have limited the number of mental health sessions per calendar year.  Check with your insurance company to see when this act when into place and how it affects the number of sessions permitted under your specific plan.)  This Mental Health Parity Act may not apply if you are self-employed and purchase either individual or HSA health insurance. 

We can not advise you regarding your decision to use insurance but believe information can aid you in making an informed choice that is best for you Hopefully this information, along with a review of your insurance plan coverage and benefits, will aid you in doing so.

Some Information About Different Types of Insurance Plans

What is the difference between PPO, HMO & POS?

("Understanding the Managed Healthcare Alphabet: HMO, PPO, & POS" taken from www.about.com)

Managed Healthcare Plans are types of health insurance policies that help employers offer their employees discounted services by negotiating reduced charges with hospitals and physicians. There are three basic types of Managed Healthcare Plans:

HMO: A Health Maintenance Organization, or HMO, provides employers a way to take care of all their employees' health care needs with reduced costs by negotiating with specific doctors, hospitals, and clinics. Generally, these specific providers must be used by the employee for the reduced fees.  (Although Darlene is not on any HMO panels, many of the HMO-Illinois plans have an out-of-network benefit paying at 50% of the hourly rate.  If you have HMO-Illinois insurance, check with them to verify if they have an out-of-network mental health benefit and what limitations, if any, they have.  If there is an out-of-network benefit, full payment is due at the time of service and a comprehensive receipt will be provided for you to submit for claim reimbursement at the quoted rate.)

PPO:
In a Preferred Provider Organization, or PPO, an employer can also provide employees with reduced costs as with an HMO, but the employees can choose the physician they want to see instead of being restricted to the HMO providers. An employee can choose between a member or nonmember provider. The member provider would be the least expensive choice for the employee.

POS: With a Point of Service plan, or POS, employees can choose their own physician that has previously agreed to provide services at a discounted fee. In a POS the employee would have to use the chosen physician as a gateway first before moving on to a specialist. In other words, whenever the employee would have a medical issue the POS physician must be contacted first in order to obtain the most benefit from the insurance plan. 

SESSION FEES

The initial diagnostic evaluation is a one-hour session and the fee is $160.00 prior to provider discounts for full-fee and/or insurance plans.  For discounted self-pay (see below) the fee may range from $60.00 to $140.00, depending on total family income.

Subsequent sessions are generally 39 to 50 minutes long and the full fee is $120.00. Discounted self-pay fees for this length of session range from $60.00 to $110.00. Based on clinical need and your insurance's contractual benefits, some sessions may be for longer times (>53 minutes). Fees for these 53+ minute sessions range from $85.00 to $160.00. (See below.)


IN-NETWORK PLANS

Following are the insurance companies for which I am a contracted provider and am considered "in-network".  I have contracted with these insurance companies and agreed to a discounted fee which may be as much as 30-40% lower than my normal hourly rate.  Therefore, if your copay is a percentage of the fee, this will be based on the discounted provider rate. For these plans, I have agreed to bill your insurance company directly and await payment of the difference between the copay payable at the time of service and the benefit your insurance company has agreed to pay for each date of service.  (This assumes any annual deductible has already been met.)  

All that is required at the time of the initial diagnostic evaluation is a copy of both sides of your insurance card and payment of your portion of the session fee (usually just the session copay or coinsurance, but may be the full amount of the fee if you have not met your calendar year deductible in full).

Blue Cross/Blue Shield of Illinois (BCBS) PPO plans (not a provider for HMO plans) www.BCBSIL.com

In order to determine if I am a provider for your plan, the number of sessions permitted annually, your annual mental health deductible and per session copay, you may either:

~ Call the customer service number on the back of your health plan identification card 
~ Look up this information on your insurance company's web site 
~ Provide Darlene with the following information at the time of scheduling our first appointment and I will verify insurance benefits:
      ~ Client name
      ~ Insured name
      ~ Client date of birth
      ~ Identification number
      ~ Group number

OUT-OF-NETWORK PLANS (BUT I MAY BE ABLE TO BILL YOUR INSURANCE COMPANY DIRECTLY THROUGH WWW.AVAILITY.COM)

  Aetna www.aetna.com
  Humana www.humana.com
  CIGNA www.cigna.com


Although I am an out-of-network provider for the above plans (and therefore my fee is not automatically discounted), I have agreed to bill them directly.  This means that I will be assigned the benefit and await payment beyond the deductible, copays, and coinsurance.  Please see "In-Network Plans" above for handling. 

OUT-OF-NETWORK PLANS NOT INCLUDED ABOVE

For all other out-of-network plans, comprehensive receipts will be provided at the time of payment for the session.  You may either mail, fax, email, or enter information onto your insurance company's claim website, depending on your insurance company's policies and procedures.  Insurance companies have greatly advanced in their handling of claims filed directly by insureds rather than providers and may be able to issue a refund (the difference between the amount you have already paid and your plan benefit) in as little as ten days, depending on the company and their procedures.

If you have HMO Illinois insurance, please be advised that you may have an out of network benefit you may be able to utilize. Typically, this is limited to those clients with "non-serious mental health disorders", per HMO Illinois contractual provisions. This is because if you have a more serious disorder, such as major depression or schizophrenia, they want you to be able to be seen regularly at the lowest rate to you for as long as is necessary clinically.

If you are not sure, you can call the number for HMO Illinois on the back of your insurance identification card for their policy and also how to be reimbursed, since I am not able to bill them directly. My experience has been that if you qualify for the mental health benefit for out of network, HMO Illinois pays at 50% coinsurance rate.

OTHER INSURANCE TERMS TO BE FAMILIAR WITH

DEDUCTIBLE

A deductible in an insurance plan is a specified amount of money that you (the insured) must pay before your insurance company will pay anything toward a claim.

COINSURANCE

Coinsurance refers to the portion (usually a predetermined percentage) of each session fee (once the deductible has been met) that the insured is responsible for.

COPAY

Copayment is a fixed dollar amount (generally not a percentage) for a covered service, e.g. office visit, paid by a client each time a medical service (counseling session) is accessed. It is due at the time of service.

OUT OF POCKET MAXIMUM

Out of pocket maximum/limit is determined by the contract negotiated with your insurance company either by your employer or insurance exchange. This maximum represents the most you have to pay for covered services in a plan year. After you spend this amount on a combination of deductible, copayments, and coinsurance, your health plan pays 100% of the costs of covered benefits. 

NOTE: The out of pocket limit DOES NOT include your monthly health insurance premiums.

SELF-PAY FEES

Fees for self-pay are the same as for clients using insurance.   However, I want to be able to provide counseling to those who either have no insurance whatsoever, their plan benefits are extremely limited, or they simply prefer paying out of pocket for privacy purposes.  Therefore, you may qualify for a discounted fee as low as 50% of the full fee.  I ask that you be willing to divulge your annual family income if you are requesting a discounted fee and also that you be willing to show proof of income.  If you do not have insurance coverage or the coverage you have is very limited, ask about discounted fees when scheduling your first appointment.










                                                                                   Offices in Northbrook and Arlington Heights
                                                                                 
  1500 Skokie Boulevard, Suite 560, Northbrook, IL  60062
                                                                                     814 W Happfield Drive, Arlington Heights, IL   60004
                                                                            Telephone and Voicemail for Both Locations:  (847) 498-8925 X2
                                                                                              Email: 
DMorganLCPC@AOL.com















                                         

 

 




 
 
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