Outpatient Mental Benefits in the PSHB Program

OPM has long required that plans pay the same benefits for physician visits or hospital stays whether due to either physical or mental illness. This requirement is called "parity," and, at face value, seems to eliminate any distinction between physical and mental health benefits. It represented a significant advance in covering clinically necessary hospital stays for mental illness. In 2010 the government issued regulations requiring all employer-sponsored health plans to meet an even stricter version of parity. Under these regulations, plans are no longer allowed even to charge separate deductibles for physical and mental health or substance abuse services. In theory, all PSHB plans will now pay for unlimited mental health services without even a small difference in cost sharing. 

The catch is that all plans select the providers for their networks and will rarely if ever use providers whose practices emphasize weekly sessions of "talk therapy." Nor will plans reimburse full costs for services provided by a psychiatrist of your choosing. Instead, they provide a limited number of plan-affiliated psychiatrists, and often rely mainly on the services of clinical psychologists, clinical social workers, and other non-M.D. staff. 

Few of the HMO plans offer any mental health services outside of the plan network, or outside of pre-approved treatment plans. The major exceptions are the HMOs with an Opt-Out or "Point of Service" provision. In contrast, most of the national fee-for-service plans offer a relatively unconstrained out-of-network benefit, as do Consumer-Driven and High Deductible plans. If you expect to use an out of network provider, setting up a Flexible Spending Account during Open Season can provide substantial savings.