115. How does a maximum allowable benefit affect treatment?

There are two ways that your insurance may set a maximum limit on your benefits for psychological tratment. First, they can set maximum per session fees. Second, they can set maximum annual fees or a maximum number of sessions per year.

Maximum per session fees can significantly increase the cost of using out of network benefits. Many employers now insist on out of network benefits, because of complaints about the lack of providers within the networks. But, if the managed care fee is very low, and if they use this fee as the maximum allowable charge for a session, then the consumer is responsible for the difference. This difference becomes very large, if the managed care rate is very low, making it more difficult for people with modest means to afford to go out of network. It is another way of restricting access to treatment.

Maximum annual fees or maximum number of sessions per year have the same impact, but in a different way. If a managed care company will only pay for 20 sessions per year, your benefit changes depending on when you develop a psychological problem. If you begin treatment in January, you are likely to exhaust your benefits, and become responsible for the full cost of treatment. Many people discontinue treatment because of this limit, and ultimately their problems return. It is a serious blockade which prevents many people from receiving treatment they desperately need. On the other hand, if you start treatment in the second half of the year, you can continue in treatment uninterrupted, as you become eligible for additional sessions after January first. This limit discriminates against people who start treatment early in the year.