Paying for Care – Health care coverage for Stress

If you’ve paid attention to national news at all lately, you’ve probably heard or read about the call for health-care reform. Many people are experiencing difficulty accessing the care they need, even if they have private insurance from an employer or other source. Nearly across the board, employers are asking workers to contribute more toward their health care, forcing many people to rethink their care, and possibly even put off care that they need. The National Coalition on Health Care, a nonprofit, nonpartisan group of more than 70 organizations working together for better health care for all Americans, reported that employees who are cov­ered by health insurance through their jobs are paying 120 percent more toward copays and deductibles than they were in 2000. The cost to an employer for a single health plan for a family of four averaged $12,700 in 2008. That means that the average health plan costs for a small company with 20 employees would be more than a quarter of a million dollars each year. To offset their costs, employers are asking workers to contribute more and more toward their insurance. The average cost to employees in 2008 was $3,400.

These rapid and significant increases in the cost of health care are squeezing the budgets of employers and individuals, but, hopefully, health-care reform will soon be under way, and services will become more available and equitable. If you are covered by a parent’s insur­ance and can get all the care that you need, consider yourself lucky, because many people do not have that advantage.

Locating and getting access to help for stress-related problems can be particularly challenging, because the problems can be physical, psychological, or both. As you know, exposure to long-term stress can lead to problems ranging from anxiety and depression to colitis, asthma, and sleep disorders. A doctor treating a patient for a stress-related medical problem—migraines, for instance—might recognize that stress is an underlying cause for the condition and recommend that the patient consult with a psychologist or psychiatrist. While your insurance might pay for you to see a doctor about your frequent headaches, it may not provide coverage, or may provide only limited coverage, for psychotherapy.

Another problem is that, while an insurance company normally will cover costs associated with a serious health event, such as a heart attack (which, as you know, can be stress-related), it often is reluctant to cover costs of preventative measures, such as a gym membership, yoga classes, lifestyle assessment, or counseling. It’s ironic that try­ing to find treatment for stress-related disorders can turn out to be so stressful!

Gaining access to mental health care can be especially challenging. Many health-care plans include very limited coverage for counseling or psychotherapy, forcing families to make up the difference between what their insurance covers and the cost of treatment. Psychotherapy fees can cost upward of $75 for a 45-minute session, making the cost prohibitive to many families and individuals.

Hopefully, this situation will improve beginning in January 2010, thanks to a law enacted by former president George W. Bush in 2008. The mental health parity law requires group health plans to provide the same coverage for mental health conditions such as depression, substance abuse, and bipolar disorder as they would for conditions such as heart disease or cancer.

This law won’t benefit everyone, however, as it doesn’t apply to companies with fewer than 50 employees or to people who buy their own insurance. Still, it will benefit some and may help to raise aware­ness of issues associated with mental health and its treatment. Mental health advocates worked hard to get the law put into effect, and it’s considered a victory in the fight to get treatment for mental health on par with that for physical health.

With more than 45 million Americans uninsured, unemployment on the rise, and the number of employer-provided health plans declining, an increasing number of Americans are relying on pub­licly funded care, or simply not getting the care that they should.

Health-care plans for children are available, meaning that no child should be left without care, but the applications can be complicated and too difficult for many people to complete. Experts and groups such as the National Coalition on Health Care are working to figure out how to solve these problems as they anticipate an increasing need for health-care services, particularly in the area of mental heath.

If you’re like most teenagers, you probably don’t spend a lot of time thinking about health insurance. It simply isn’t a topic that’s high on your radar. If you find yourself in a situation where you feel you need treatment that your insurance doesn’t cover and your fam­ily can’t afford to pay for it, however, it may suddenly become an important issue. Let’s take a look at the major programs and types of insurances available.

Employment-based health insurance. This is health insurance that an employer provides as a benefit to employees, and some­times, but not always, their families. The insurance may be pro­vided at no cost to employees, although that is becoming increasingly unusual. Most companies require workers to share some of the costs in the form of copays or deductibles, with requirements vary­ing tremendously from company to company. And it’s important to understand that not all companies offer insurance to employees. In Delaware, for instance, 64.2 percent of all companies provide some level of health-insurance overage for employees, according to the Centers for Disease Control and Prevention. In Montana, however, only 40 percent of all companies offer insurance as a benefit to employees. Larger companies are far more likely to provide insur­ance than smaller ones, and coverage may vary tremendously under this broad umbrella of insurance, depending on the type of policy.

Insurance from one company might come in the form of a Health Maintenance Organization (HMO), for instance, which is a type of health-care coverage that offers care from doctors, hospitals, and other providers with whom the organization has contracted for ser­vices. An HMO generally requires approval for many treatments that would automatically be covered with another type of plan, such as a Preferred Provider Organization (PPO) or a Point of Service (POS). HMOs only cover care provided by approved health-care providers who participate in the HMO’s plan and agree to its guidelines and restrictions. PPOs are managed care organizations that use hospitals, doctors, and other providers who agree with an insurer to provide care at lower costs to the insurer’s clients. PPOs generally are more flexible than HMOs, and usually allow you to choose which health­care providers you wish to use. POSs are sort of combinations of HMOs and PPOs. POSs allow you to see any provider you want, but you’ll pay more out of pocket if the provider isn’t part of the insurer’s network.

Privately purchased health insurance. If someone does not have a job or works for a company that doesn’t provide health insur­ance, or is self-employed, he may need to purchase his own insur­ance. Who gets insurance and how much he’ll have to pay for it varies from state to state. Insurance costs much more in some states than in others, because each state has its own regulations regarding insurance costs. Regulations regarding who can get insurance also vary. In most states, for instance, an applicant can be turned down for insurance based on his health status.

Government-provided health-care coverage. People who don’t have jobs that provide health insurance and can’t afford to buy their own may qualify for Medicaid or the State Children’s Health Insurance Program (SCHIP), which covers anyone who qualifies up to age 18. In 2007, 83 million people were covered by government programs, including 23 million children. Still, more than 8 million children remained without health insurance, according to govern­ment statistics.

If your family is a low-income one and doesn’t have any health insurance, you might qualify for government-provided health-care coverage. Medicaid is a federal program, but it’s state-administered, which means that requirements for eligibility vary from state to state. A big problem occurs when a family’s income is too high to qualify for Medicaid, but they don’t have enough money to cover medical expenses. You can learn more about who is eligible for Med­icaid at www.cms. hhs. gov/medicaid/eligibility or www.cms .hhs. gov/whoiseligible .asp. More information about the SCHIP programs is available at www.cms. hhs .gov/schip or www.insurekidsnow .gov. You also can learn more by calling 1-877-KIDS NOW.

If you are 18 or younger and do not have health insurance, you should know that you often have the right to coverage. Children can be covered by Medicaid in some states; in families where parents don’t qualify for Medicaid but can’t afford to buy health insurance, children should be covered by SCHIP.

No matter what type of insurance you have, or how it’s provided, it’s important to read the terms and applications carefully to see what might be covered and what isn’t. Also, try to determine the terms of payment for services. Most doctors will submit a request for payment to your insurance companies, but some plans require that you make the payment to the doctor and then submit a claim the insurance company for reimbursement. If you must wait for reimbursement, be sure to make arrangements for payment with the doctor’s staff.