Seeking help when struggling with mental health problems can be an overwhelming challenge. Unclear rules and miscommunication surrounding insurance coverage can exacerbate the issue, unfortunately. It’s important to find out what your insurance does and does not cover, so you can feel confident in approaching a medical professional about your health, and so you can be empowered to seek treatment.
While most insurance companies and resources help adults diagnosed with mood and anxiety disorders seek medication for their condition, it becomes much more difficult to figure out whether an insurer provides coverage when your condition requires a form of treatment that is not first-line. Transcranial magnetic stimulation (TMS) is an alternative treatment method for treatment-resistant depression and is considered a higher level of care. Approved by the FDA and found effective through numerous peer-reviewed studies, TMS has proven to be a promising treatment method for countless Americans seeking relief for their depressive symptoms.
While not a first-line treatment, TMS’s recent approval through the FDA and proven efficacy means it is currently covered by a large number of commercial and public insurance companies. However, when figuring out whether your insurer covers a particular treatment, it’s important to go straight to the source.
Does My Insurance Cover TMS?
Most insurance companies currently cover TMS, including at least 36 insurers, at least five Medicare Advantage plans and at least one Medicaid plan. According to NeuroStar TMS, over 300 million consumers have an insurance policy that covers their specific TMS technology. Some of the insurers currently covering TMS in their policies include:
- BlueCross BlueShield
- Commonwealth Care Alliance
- Fallon Health
- Magellan Health Services
- And more.
When determining whether your commercial insurance provider covers TMS, consider utilizing a plan finder, or check your provider’s policies and resources to find information about your treatment options. Other resources exist to check if your commercial or government plan covers TMS treatment. Furthermore, find out if your TMS treatment provider is in-network with your insurance provider.
In-Network and Out-Of-Network
When figuring out how insurance coverage works for your particular treatment needs, it helps to know whether your treatment provider is in-network or out-of-network with your insurer. What this means is that, if your treatment provider is in-network with a particular insurer, you will have to typically pay less because in-network healthcare providers have negotiated discounted rates with insurance companies. However, if your health care provider is out-of-network, you will have to cover the difference.
The best way to figure out whether a provider of your choosing is in-network with your particular insurance provider is to check your insurance card, look for the customer service number, and contact them to inquire about the particular provider you are thinking of utilizing. When a healthcare provider states that they accept certain insurance providers or are working with certain insurance providers, this does not necessarily mean they provide in-network costs.
In-network costs are always cheaper than out-of-network costs, but if there are limited healthcare providers in your area, you may be consequently be limited in your options. But if the choice is yours, be sure to do your research – often all it takes is a quick phone call to ensure that your chosen healthcare provider is working with your insurance company.
Because TMS is a higher form of care, there are certain requirements and considerations that must be met before an insurer is going to cover their part of the costs for your treatment. These requirements vary from treatment to treatment and from insurer to insurer, but commonly, for TMS, they are:
- A patient must have sought pharmacologic help for their depression (antidepressants), to no avail.
- A patient must have sought additional ‘augmentation strategies’, which refers to trying different types of antidepressants to ensure that a patient is not better off simply switching medication.
- A patient must have undergone some type of talk therapy/psychotherapy, commonly cognitive behavioral therapy (CBT) without any success.
If a patient has proven to resist all of the above treatment plans, then they are commonly qualified for ‘treatment-resistant depression’ and can seek TMS treatment as part of their insurance plan. However, most healthcare providers still require authorization from insurers before they can begin treatment. What this typically means is that, during a free or paid consultation, the TMS treatment provider will closely monitor you and ask specific questions to compile a dataset to be sent to that person’s insurer to ask for authorization for the treatment. Typically, this is how an insurer checks for the qualifications described above (by having the treatment provider ask about prior treatments, medications, responses, etc.). An insurer will commonly require a patient to have tried at least one form of psychotherapy, and at least two antidepressants (but often, as many as four are needed to adequately consider someone ‘treatment resistant’). From there, a psychiatrist may query you about your depression treatment history to write a doctor’s recommendation to the insurer, further giving them reason to cover the treatment.
The time it takes to approve coverage and send authorization back to the healthcare provider depends mostly on the insurer, as well as the relationship the healthcare provider has with the insurer. In-network healthcare providers will typically get a faster response than out-of-network healthcare providers. One to two weeks is about average, but it may take up to three weeks. For out-of-network providers, the process can take weeks, or even months in certain cases.
Most treatment providers have Intake Coordinators that work with patients and insurers to expedite the process and smooth things out. Intake Coordinators can also help a patient navigate their insurance coverage and figure out how much of their costs will be covered by their insurer. The exact figure differs from insurer to insurer, and it is best to consult your insurance company to figure out how much you have to pay, how much your deductible is (if you have a plan with a deductible), and if your insurance covers costs entirely after a deductible, or if there is anything left of the bill for you to foot.