How much will my insurance cover? Navigating coverage for mental health issues can be tricky

Issue August 2004

Q:My husband has, after many years, agreed to get help for his drinking. We were surprised to learn that his health insurance benefits would not cover a Betty Ford-type rehab center, and would only provide weekly outpatient counseling. We were further dismayed (and angered) to find, despite Massachusetts "mental health parity" law, that his insurance limits him to something like eight sessions. That seems like so little for such a big problem, when in the past he's tried to stop drinking many times on his own and failed. Does it make sense to you?


A:Concerns about the limits of managed care, particularly related to gaining access to treatment, have been brought to our attention a number of times recently, so we will use this opportunity to piggyback onto last month's column that addressed the difficulty of finding an available therapist.

Prior to managed care (which hit the scene abruptly in the mid-to-late 1980s), it was common for individuals with alcohol or drug dependence to spend about a month in an inpatient rehab. Most of these, like the Betty Ford Center, were based on the "Minnesota model" of detox followed by weeks of individual and group therapy (along with such ancillary activities as family therapy, exercise, nutritional counseling, meditation, use of AA, etc.) designed to reduce denial, foster acceptance of alcoholism/addiction as an illness and provide an initial grounding in sober living. Almost all of the facilities of that type in New England no longer exist. Individuals who still enter such programs (generally in other parts of the country) usually do so on a self-pay basis, at a cost in the range of a year's college tuition. The rare health plans that do cover such facilities often apply to members of labor unions.

In Massachusetts today, health insurance will generally cover detoxification only if the individual has true withdrawal symptoms (such as "the shakes"). In those cases, a typical length of stay might be four days - just until the acute withdrawal symptoms abate and the patient's vital signs return normal. Some plans may also cover a period (often two weeks) of "partial hospital" (day) treatment, in which the patient lives at home but spends about six hours a day attending group therapy, while receiving individual case management and psychiatric oversight. That's as close as most patients are going to come to "rehab" when insurance is picking up the tab. Following partial hospital treatment, or instead (if it isn't covered), insurance usually provides limited coverage of "outpatient" care, which usually means one session per week (individual and/or group therapy). As to the limited number of sessions that your HMO will authorize, that's a large enough topic to wait for our next column. Meantime, let us remind you that LCL's staff deal with the insurance morass all the time (though our own services require no payment), and are available to help you navigate.


Questions quoted are either actual letters/emails or paraphrased and disguised concerns expressed by individuals seeking assistance from LCL. LCL's licensed clinicians will respond in confidence.