Health care hurdles frustrate lawyer hoping to keep therapist

Issue November 2010

Q. My anxiety spiked when recently I got my first job (in a small firm) after passing the bar, which meant having to face not only the challenges of "real life" practice -- about which there is so much I have yet to learn -- but also the need to make loan payments, pay the rent, begin planning a family, etc. I didn't want to become accustomed to the tranquilizers that my primary care doctor prescribed, so I got into therapy (or counseling, I'm not sure which), and it has helped.

I've been getting health insurance through my wife's half-time job, and they just changed to another HMO that doesn't cover my therapist. Because my income at this point remains quite limited, I may also qualify for Massachusetts' "Commonwealth Care," but I don't see the therapist's name on that list either. I'd rather not have to start with someone new - is there a way around this?

A. Efforts at universal health coverage are far from perfected, and you have come across an all-too-familiar obstacle. While most primary care physicians and hospitals are covered by the majority of managed care plans, that is not the case for most behavioral health providers (for a variety of reasons that need not be detailed here).

In many cases, the new HMO will allow for a few months of "transitional" coverage for your "out-of-network" therapist. (By the way, for practical purposes, you can consider "therapy" and "counseling" to be synonyms.) In addition, if you have the option of switching to a PPO or POS plan, they will cover providers outside their network, but generally at greater cost to you.

After that transitional period, you will need to wrap up with your current therapist or negotiate a manageable self-pay fee, if possible. If your law firm offers a "flexible spending account" (sometimes called a "cafeteria plan"), these costs can be effectively reduced by paying them out of pre-tax income. Otherwise, either your current therapist or an LCL clinician can review the new HMO's provider list with you with an eye toward choosing a good successor therapist.

Commonwealth Care -- though an excellent alternative to no insurance at all -- is built upon the existing Mass Health (Medicaid) system and uses that provider list. The great majority of behavioral health providers on that list, you will find, are clinics (either freestanding or hospital) or large incorporated practices. In such systems, you can expect an initial intake evaluation and subsequent referral to the clinician who will see you for further sessions, which may or may not be the same person.

LCL would generally not be able to refer you to a particular individual, and we have found that there is often a months-long wait before the initial visit.

The inscrutable world of managed care never ceases to baffle, and we cannot possibly provide a guide through its labyrinthine twists and turns in this column, but if you arrange an appointment with one of our clinicians (at no cost), we can help you navigate. LCL offers evaluation, consultation, referral and more, but does not provide ongoing therapy/counseling. To protect you from any conflict of interest, our clinicians also may not refer you to their private practices.