Start with the name on your card
"Blue Cross" on a card in Michigan can mean several different products. The first thing to sort out is whether you have a Blue Cross Blue Shield of Michigan PPO plan or a Blue Care Network (BCN) plan. BCN is the HMO side of the company, and the two work differently for therapy.
Blue Cross Blue Shield of Michigan describes the difference plainly. With an HMO, you pick a primary care provider, you generally need a referral before seeing other professionals (except in an emergency), and visits outside the network typically are not covered. With a PPO, you do not need a primary care provider, you can see any professional without a referral, in or out of network, and staying in network keeps your costs lower.
Your plan may also come through an employer, through the individual market, or as a Medicare Advantage plan. Those details change your benefits, so keep your card handy for the steps below.
What in network means for your bill
Blue Cross calls in-network clinicians "participating providers." They agree to accept the plan's allowable amount for a service. Blue Cross gives a simple example: a provider charges $150, the allowable amount is $90, and as a member you are only responsible for your share of the $90. The discount shows up on your Explanation of Benefits (EOB).
Out-of-network clinicians have not agreed to that amount. Blue Cross explains that you are responsible for the difference between the provider's full charge and the allowable amount, which it calls balance billing. PPO plans include some out-of-network benefits but usually at a higher share; HMO plans generally do not cover non-emergency out-of-network care at all. Out-of-Network Therapy Benefits and Superbills, Explained covers that route in detail.
Dr. Lehmann and Blue Cross
Dr. Lehmann's practice is in network with Blue Cross Blue Shield PPO. That is the only in-network plan listed for the practice. If your card says Blue Care Network, or if you have any other BCBS product, call the office at (248) 270-2030 to confirm before your first visit, and check with Blue Cross as well. The fees and insurance page has the current details.
Where to find your mental health benefits
For Blue Care Network members, Blue Cross says the member account (under My Coverage on the website or app) lists mental health and substance use disorder services as their own group, with three things worth checking. PPO members can look in the same account; the plan documents and the customer service number on the back of the card are the backup.
- Whether you have a copay or coinsurance for an outpatient mental health visit
- How many days or visits the plan will help pay for
- Which services need prior authorization
While you are logged in, also check your deductible and how much of it you have met. Blue Cross explains that you pay the full allowable amount for covered care until the deductible is met, then share the cost through coinsurance, and that copays can apply before or after the deductible depending on the plan.
Questions to ask Blue Cross customer service
- Is [clinician's name] in network for my specific plan for outpatient psychotherapy?
- What will I pay for a 60-minute psychotherapy visit before and after my deductible?
- Is there a visit limit or a prior authorization requirement?
- Are video sessions covered the same way as office visits?
- If I see someone out of network, what percentage does the plan pay, and is there a separate out-of-network deductible?
Use the Find a Doctor tool as a starting point, not the final word. Blue Cross notes that it shows only in-network providers and still recommends calling the provider to ask whether they take your plan.
Blue Care Network's behavioral health line
Blue Cross says BCN members can call its behavioral health line at 1-800-482-5982, 24 hours a day, without talking to a primary care provider first. A care manager evaluates needs and helps with referrals. If you have a PPO plan, call the number on your card instead. In a life-threatening emergency, call 911 or 988.
Parity, denials and appeals
Federal and Michigan parity laws generally require that copays, coinsurance, visit limits and prior authorization rules for mental health care be no more restrictive than for comparable medical care. Which rules apply can depend on whether your employer's plan is insured or self-funded, which your benefits office can tell you. Mental Health Parity: What Your Insurance Must Cover in Michigan explains the details.
If Blue Cross denies a claim, the denial notice explains how to file an internal appeal and the deadline. Michigan's Department of Insurance and Financial Services (DIFS) says insurers must decide internal appeals within 30 days for care you have not yet received and 60 days for care already received. If you disagree with the final decision, you may be able to ask DIFS for a free external review within 127 days. DIFS answers questions at 877-999-6442, Monday through Friday, 8 a.m. to 5 p.m.
Keep a simple paper trail
Insurance questions are easier when you can show what you were told. Note the date, the name of the person you spoke with and any reference number for each call. Save EOBs and compare them with the statements from your therapist. If something does not match, a call to customer service with that record in hand usually resolves it faster.
Coverage questions should not delay getting help for long. If you are ready to start therapy for anxiety or depression, you can sort out benefits in the same week you make the first call.