High Co-Pays, High Deductibles, Low Reimbursement Rates – This Is Our Reality

From the memoirs of Psychotherapist Dr. Karen Ruskin – It breaks my heart each time I receive a call from a potential new client who is unable to find a skilled mental health professional to schedule an appointment with, due to finances. Allow me to explain by providing you with just but one example that happened today. Today is consistent with the theme of what is happening due to the increase of co-payments and the increase of deductibles for the person who wants mental health services, along with the decrease of reimbursement rates for services. This is our reality that is going to get worse as Obamacare hits the masses.

A woman called me on the phone today interested in becoming a client of my counseling practice. She wants a specialist in marital issues. She has an insurance that my group is not a “provider” for, we are not “in network”, as the reimbursement rate pays significantly less than half of the reasonable and customary standard therapist rate. Therefore, a therapist cannot make a living on this particular insurance’s reimbursement rate, which is in essence why we chose not to be providers for this particular insurance. What this means for the potential new client is; she must pay up front per session the session fee to the therapist she is meeting with, if she wishes to meet with a non network provider. Then, the therapist provides her with a receipt upon which she is invited to submit to her insurance company for reimbursement. Whatever portion her insurance company reimburses her is the amount of money she will get back.

The scenario explained above for some clients in a financial situation where money is not a stress, this concept works just fine for them (that is the minority of the population). For many, this financial plan does not work for them. For this particular woman – this plan does not work for her financial situation. She explained to me that for her particular plan she has a $500 deductible. So, before she can even get any portion of reimbursement she has to pay per session up until she reaches $500. (And she is one of the “lucky” ones. So many people are experiencing a drastic increase in their deductible just like her, and theirs went from $500. to $5,000.). She further explained, even if she sees an “in network” therapist, she still has to meet this deductible. Then, once she has met her deductible, insurance will cover 70% of the fee that the insurance company has decided is the fee allowance (again, which is significantly less than half of the standard therapist rate).

Let’s take this a step further. If she meets with someone in network, she struggles with the deductible payment, but at least once her deductible is met, her 30% portion per session she must pay is more reasonable, since the reimbursement rate from the insurance company is so very low. If she meets with someone not in network a “non-provider”, she also struggles with the deductible payment, AND she struggles with the 30% co-payment, as the therapist has their own standard reasonable and customary rate. The problem for this potential client is that money number is too high for her. And it is not because the therapist’s standard fee is outrageous, it is rather the number is too high for her as she is on a tight budget. The woman shared her disappointment and reported that she has been researching therapists who have an expertise in marriage counseling, has spoken to several and each of them report to her the same story. They each have shared that they have chosen not to be a provider for her particular insurance due to its low reimbursement rate. Needless to say, yet again, she walks away without an appointment scheduled. This scenario I am afraid to report is happening more and more.

Let’s take this even a step further. Imagine the scenario where the client does all the “right” things. She finds a therapist “in network” and pays her deductible. Well, are you ready for this? For some plans, there are limits on how many sessions are allowed per calendar year. Imagine that! So, you wait for months to get in with a therapist who has a wait list because they are the only therapist in town who is on your plan who actually specializes in the problem you need help with. You meet for several sessions, establish a connection, feel safe to explore your thoughts and feelings and finally meet your deductible. You get a few sessions in where you utilized your co-payment plan, but your problem is not resolved yet, thus, you wish to continue therapy. But, your plan only allows for 8 visits per calendar year. 8 visits! This limitation is disappointing to say the least.

The man whose wife passed away after 30 years of marriage and he is now diagnosed with cancer- wants counseling but he has no more sessions left. The wife who found out her husband cheated on her with her sister- wants counseling but the deductible is too high. The child who has obsessive compulsive disorder or self mutilating, single parent cannot afford the co-pay for services for her child. The woman who was raped by her father as a child and is finally speaking up as an adult whose mental health plan allows for limited sessions, she needs more but her insurance has run out- how is she going to receive help for her post traumatic stress disorder? Oh, the problems are endless, the situations are abundant, and the insurance issue is just that – an issue- and a big problem at that.

High co-pays, high deductibles, low reimbursement rates Рthis is what I am seeing more and more of in this changing landscape of mental health coverage. What does this mean for client care? Who will be seeking out and able to receive services? The client who can afford the high co-pays, the high deductibles, the low reimbursement rates Рthat is who will seek out services, that is who will receive services. Who will receive services? Those who can afford. Where does that leave the mass of the public? The poor? The middle class? Those on a tight budget? What will happen to those folk who want marriage therapy? Individual therapy? Family counseling? Problems such as substance abuse, addiction, childhood behavioral problems, infidelity, infertility, anger management, depression, anxiety, stress, schizophrenia . . . the list is endless for those of whom are and will be in need of a skilled mental health professional. What will happen to those struggling financially or on a tight budget? What I ask you?  Which therapists will be available to them? Those who are skilled? Those with great experience? Those with a good reputation?

From the memoirs of a psychotherapist who sees before her what is becoming and what is to come, it breaks my heart what is coming for our America. I have been a mental health professional for 20 years, the change I have seen before me is disturbing, frightening, outrageous, painful, and down right a huge problem. I am hopeful that by sharing what I see will help open the eyes of those who may have a voice as change makers. This problem is real, and it hurts all of us.

If you found this blog article informative, I invite you to check out my blog article entitled: 3 Ways Obamacare Negatively Affects Mental Health Care – Psychotherapist Explains.

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