LCL will help you review your health-care options

Issue October 2004

Q:I read with interest your recent columns detailing ways that our managed care health insurance plans can make it difficult to access treatment for psychological and alcohol/drug disorders. As in-house counsel to a large corporation, I have a choice of various insurance plans. Can you tell me how an HMO differs from a PPO or Point of Service plan, or other kinds of plans?

A:Choosing the best health plan can be challenging, partly because a given plan's coverage for medical/physical health services may differ greatly from what they offer for mental health/substance abuse (MH/SA) treatment.

In general, an HMO will be your least costly option, though that may be hard to believe when you see the premiums. You will need to choose one primary care physician (PCP) who will handle most of your complaints and will serve as "gatekeeper" to specialists (i.e., the PCP must authorize any services you seek from another doctor or you will have to pay for it yourself). In some plans, any specialists you see must be members of the same physician group (usually meaning that they are affiliated with the same hospital as your PCP). Most HMOs, however, have a separate mechanism for authorizing MH/SA treatment, where you obtain the initial authorization not from your PCP but via a special phone number on your insurance card. In any case, you must obtain authorization and see a clinician who is "in the network." The authorization will be for a limited number of sessions; your therapist can then apply for more authorized sessions, using a form that involves disclosure of your symptoms, functioning level, and treatment plan. If your treatment is not finished within the approved number of sessions, this process may be repeated a number of times until you have reached the annual maximum (usually 24 sessions unless you have a "biological" diagnosis).

It is very difficult to distinguish any differences between a PPO (Preferred Provider Organization) and a POS (Point of Service) plan, from the consumer's point of view. In each case, you have a choice - either to stay within the provider network, in a system virtually identical to an HMO, or to choose a provider who does not participate in the plan's network. This gives you much more freedom in selecting the clinician. However, your cost for each service will generally be higher, and there is often an annual deductible (e.g., the first $100 or more may come directly out of your pocket). Another advantage of going out of network is that you may bypass the cumbersome authorization system described above (though the annual maximum still applies). PPO and POS plans have higher premiums than do HMOs. You cannot tell what type of plan you have simply by the "brand name." That is, Blue Cross, Tufts, Harvard-Pilgrim, etc. all offer both HMOs and more flexible types of coverage.

Finally, some people still have access to the now-heady freedom of an old-fashioned "indemnity" plan, the kind that covered most of us until the mid-1980s. That type of plan will cover any licensed provider who agrees to accept insurance, and in many cases will reimburse a patient who chooses to pay the provider directly. These companies usually still impose an annual maximum amount of coverage (which does not always seem to comply with Massachusetts' Mental Health Parity law discussed last issue).

If you would like to bring all the brochures into LCL for help in reviewing your options, feel free - no authorization required!

Questions quoted are either actual letters/emails or paraphrased and disguised concerns expressed by individuals seeking assistance from LCL. Questions for Lawyers Concerned for Lawyers may be mailed to LCL, 31 Milk St., Suite 810, Boston, MA 02109, or called in to (617) 482-9600. LCL's licensed clinicians will respond in confidence. Visit Lawyers Concerned for Lawyers online at