New Clients and Insurance F.A.Q. (Frequently Asked Questions)
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I N S U R A N C E – Currently we have openings for Straight Medicare, MHN, Healthnet, Optum, United Health, and Out of Network Clients.
If you are not sure what your insurance is call the member service number on your insurance card.
We take many insurance plans including:
Straight Medicare, MHN, Healthnet, Optum, and United Health Care.
Each of these insurances has different restrictions. Some insurance plans focus treatment for 45 minute sessions while others allow for an hour.
While sessions are limited in length you may come in more than once a week if you meet medical necessity criteria.
Typically, if you have one of these insurance plans and the clinician is paneled with the plan we can bill your insurance directly.
We Do Not take the following plans – see why below.
United Health Care PPO Medicare
United Health Care HMO Medicare
Kaiser Senior Advantage
or any program built on Medi CAL benefits or where Medicare is not the primary.
Each insurance also has certain business lines and we may or may not be paneled to take that particular business line. As always, we can look up your insurance, but the best information should come directly from your insurance company. Their phone number is usually on the back of your card.
Please note, after 6 years of taking insurance I have found that often the same question will generate multiple answers when calls are placed back to back. The reason for this is that there are often new representatives, limitations to training, and the overall complexity of insurance. Truly as the customer you are responsible to know your plan and benefits, however that is often quite complex. I apologize for the complexity of these systems and wish that it could all be streamlined, however that is currently above my pay grade!
A Fuller Explanation of several Plans and things you should know and verify as an Insurance Consumer
Straight Medicare – typically has a 20% copay, however in the beginning of the year there is a deductible that must be met prior to the insurance paying anything. This means either your secondary insurance will pay or you must pay out of pocket. This amount was roughly $186 last year and increases each year.
Medicare secondary insurance- Most secondary insurance can be accessed at Lions Heart Counseling. Typically an insurance provider will pay for the copayment of the Medicare fees and your deductible at the beginning of the year. However in 2019 many secondary plans stopped paying the deductible.
When a claim is submitted to Medicare on the CMS 1500 form it will be forwarded to the secondary insurer and they will pay their portion usually within a couple of months. However, odd things can happen on the way to payment. Some insurers have a mess when it comes to paying these claims and can’t get the address right for payment, some don’t receive the statements from medicare because they didn’t pay for the link. Some insurers don’t pay their full amount because a group is out of network. Although these are rare, you may be responsible for the difference if this happens. The good news is – it is usually no more then $21.03 per session.
Commercial Insurance PPO and HMO Medicare plans. We are not contracted or paneled with this Line of Business with any insurance company. Be sure you know if you have a secondary insurance plan that pays your Medicare deductible or copays or if you have a primary Commercial insurance plan that overrides your medicare coverage. If you have a secondary insurer we can get reimbursed, if you have a Commercial plan that overrides your medicare coverage we may still be able to bill medicare directly, but you will be responsible for the copays and deductibles at the time of service. If you are not sure what your insurance is call the member service number on your insurance card.
MediCal – this is typically a secondary insurance for Medicare. Lions Heart Counseling does not take MediCal insurance as there are many restrictions. WE used to just take the 80% MediCAre benefit but due to changes by the State of California running this program and paneling all providers we opted out. Typically, when the economy drops these bills do not get paid. In fact Large local hospitals have had great problems in the past getting reimbursed. IF the hospitals with all of their sophisticated software and staff can’t get paid what hope does a small outpatient counseling company have. Some people hav taken exception to this feeling that therapy should be free. And I agree that there would be great benefit if all people had access to therapy regardless of cost. However, I can’t possibly keep a business running without revenue. If someone wants to donate a large sum of money for the treatment of indigent folks I am more than happy to design and implement that program. But there are already a large number of non-for profits and government agencies already offering these services. In my opinion those programs should be adequately funded and supported in order to help.
United Health/ Optum/ Sutter Plus
We currently don’t have any available appointments for these insurance groups. However, feel free to send an email or leave a voice message with your request to be added to our waitlist. Typically these plans offer an hour intake and 45 minute sessions thereafter.
support@lionsheartcounseling.com 844.546.6788
(OON) Out of Network
Many insurance plans will reimburse you at around 80% for working with a provider out of network. In this case you pay for the sessions and the therapist provides you a SuperBill which you then submit to your insurance company for reimbursement.
Please note, insurance is extremely complicated and this is just what I have learned in trying to run a business and provide counseling to insurance clients. This by no means is a comprehensive primer on insurance, and your best information will always come directly thru your insurance company or a licensed insurance broker.
James Meyer
President and Clinical Director at Lions Heart Counseling
Please note the views and information offered here is of my experience in billing insurance companies for the past 5 years and is by no means exhaustive to guaranteed. The best information should come from your insurance company or the insurance commissioner of the state of California. There is no express or implied warranty of the accuracy of this data. Please do your own research and if you find something contradictory or changed please let us know.