Mental Health Claims and Out of Pocket Maximums

[Guest akwallace]

We have found a discrepancy between some of our carriers, and the way that the out of pocket maximums are calculated.

One plan excludes mental health claims from going towards the out of pocket.

Is this typical?

[Guest taylorjeff]

For some carriers, benefits with inside limits do not count coinsurance / copays toward the plan out of pocket limit. In Illinois, BCBS will not give out of pocket credit for chiropractic, phys-occ-speech therapies, TMJ. They also do not give OOP credit for "other mental illness / chemical dependency" benefits.

For "serious mental illness" benefits, even though there are day limits in the plan, BCBS does count the coinsurance toward the OOP. I imagine this is to comply with mental health parity or state legislation.

[mroberts]

I think you're going to find that nothing is standard when it comes to different carriers in different geographic locations. I would say for UHC, Aetna and CIGNA, the PPO plans should be very similar regardless where the plans are written. For BCBS, this isn't going to be the case at all since there are 44 different BCBS's around the country and each does not operate the same.

With that being said, I would say that's atypical and should clearly be brought to any employer/client's attention. While many people think that mental health benefits shouldn't be as important as physical health benefits, they are dead wrong. Numerous studies have shown the need for mental health parity and the fact that it will actually lower health care costs in the long run due to the fact that many physical ailments are the result of mental ailments not being treated proactively.