Transcranial magnetic stimulation (TMS) therapy represents a revolutionary treatment for depression, yet some people who cope with depression symptoms do not pursue this line of treatment due to insurance concerns. It is important to note that insurance companies often cover all or part of the cost of TMS therapy, and the Achieve TMS team actively works with insurance companies to try to secure insurance coverage for TMS treatment sessions.
As part of our commitment to providing exceptional patient care, we work with most major insurance providers to help patients obtain insurance coverage for TMS therapy. Let’s look at some of the most common questions surrounding insurance and TMS.
What Insurances Are In-Network at Achieve TMS?
An insurance policy may provide access to in-network and out-of-network healthcare providers, such as doctors and hospitals. Differentiating between in-network and out-of-network healthcare providers is sometimes challenging, but doing so enables you to find quality, affordable medical support for various physical and mental health issues.
In-network coverage ensures an individual can access healthcare providers that agree to accept a specific rate based on an insurance plan. In comparison, out-of-network healthcare providers are not covered by an insurance plan. An individual pays less for medical services delivered by an in-network healthcare provider as opposed to an out-of-network option.
In California, Achieve TMS is in-network with the following insurance plans: Aetna®, Anthem® Blue Cross, Beacon Health Options, Blue Shield® Federal Employee, Blue Shield of CA, Cigna®, First Health® National Network, HealthNet®, HCA Healthcare™, Magellan Health®, MHN, Optum®, Prime Health Services, Provider Select, TRICARE®, and TriWest Healthcare Alliance® with VA Community Care programs. We also accept Medicare in Claremont and Mission Valley.
If a patient has Medicaid (Medi-Cal) in California, the cost of TMS treatment is not covered under any associated policies. We encourage Medi-Cal enrollees to contact their state and local representatives to advocate for TMS therapy and other mental health coverage options.
In Oregon, we’re in-network with these insurance plans: Aetna®, Blue Shield® Federal Employee, Cigna®, First Health®, First Choice Health®, Moda Health, HCA Healthcare™, Oregon Health Authority’s Oregon Health Plan (OHP) (fee for service only), PacificSource, Providence Health Plan, Providence Preferred, Regence BlueCross® BlueShield® of Oregon, and TRICARE®.
For individuals in Alaska who are seeking TMS treatment, we’re in-network with the following insurance plans: Aetna®, TRICARE®, HCA Healthcare™, Premera Blue Cross, Cigna®, Optum®, First Choice Health®, and TriWest Healthcare Alliance® with VA Community Care programs. We also accept Alaska single case agreements for MHN.
If you are located in California, Oregon, or Alaska, and your insurance is not listed above and is a preferred provider organization (PPO) plan, we may still accept your insurance for TMS and can review your insurance benefits and depression treatment history.
What Is a Carve-Out Plan?
In addition to providing traditional insurance plans, some insurers partner with outside vendors for mental health services. Blue Shield of California, for example, works with Magellan Health to deliver mental health benefits to its enrollees. But if an individual has a Blue Shield of California insurance card, he or she is unlikely to see any information about Magellan on the card itself. Instead, all of the information about Magellan is likely included in this individual’s policy paperwork.
At Achieve TMS, our offices are often in-network with a “carve-out” option that allows us to apply in-network benefits. Therefore, we may be able to help a patient take advantage of a carve-out option, even if we fall outside the network of his or her primary insurer.
Some of the carve-out plans that we support include Blue Shield of California (carves out to Magellan), United Healthcare (carves out to Optum), Providence Health (carves out to Optum), and Healthnet (carves out to MHN). Carve-out plans can be confusing, and if a patient has questions about whether we offer a carve-out option based on his or her insurance plan, we will gladly respond to them.
How Much of the Cost of TMS Therapy Is Covered by Insurance?
The cost of TMS therapy covered by insurance varies based on the plan and insurance company. Sometimes, the full cost of TMS therapy is covered, or patients may be required to pay a copay or deductible, coinsurance, or both.
For a patient who has a copay, he or she will pay each time a TMS treatment session is completed. An insurance company defines the number of TMS treatment sessions covered by an insurance policy, and this number often falls between 20 to 40 sessions.
In cases where a patient has a deductible, he or she is required to cover the cost of TMS therapy until his or her deductible is met. Once the deductible is met, a patient’s insurance company will cover a portion or 100% of the cost of his or her TMS therapy sessions.
With co-insurance, a patient is responsible for a portion of the cost of TMS therapy. For instance, if an insurer covers 90% of the cost of TMS therapy, a patient will be responsible for the remaining 10%.
Achieve TMS assigns an intake coordinator who reaches out to a patient’s insurance company after he or she completes a free initial consultation with us. Our intake coordinator requests a “Quote of Benefits” that defines the specific benefits provided by a patient’s insurance plan. After our intake coordinator reviews a Quote of Benefits, a patient can find out how much of the cost of TMS therapy is covered by his or her insurance.
We do our best to provide our patients with an appropriate cost of TMS therapy, regardless of whether a patient requires a copay or deductible, and/or co-insurance. Since we negotiate with insurance companies individually, the overall cost of TMS therapy varies.
Does My Insurance Require a Referral or Anything Else to Get TMS Treatment?
Most insurance companies require Achieve TMS to get pre-authorization before TMS therapy is performed.
We collect information during an initial patient consultation that allows us to submit a pre-authorization request to a patient’s insurance company. This information includes a patient’s medication history and a description of any previous depression therapies that he or she may have tried.
Each insurer has its own medical guidelines that must be met before it authorizes a patient to receive TMS therapy. We work closely with insurance companies to learn about each insurance provider’s medical guidelines, and our intake coordinator will explain these guidelines to a patient.
How Long Does It Take to Get Authorization for TMS Therapy After I See a Doctor?
For patients with in-network coverage for TMS therapy, the authorization process is usually seamless. Our office submits a patient’s pre-authorization immediately after an initial evaluation, and an insurer usually responds to us within five to seven business days. In very rare instances, an insurer may take 30 days or longer to respond.
For individuals who are coping with severe depression and believe they may hurt themselves or others, or experience recurring thoughts of suicide or death, call 911 for immediate medical assistance.
How Can I Learn More about Insurances That Cover TMS?
Ultimately, insurance can be complicated, and it may be tough for people to understand their coverages related to various alternative depression treatments, including TMS therapy. The Achieve TMS team can discuss TMS therapy and insurances that cover TMS with patients, and in doing so, take the guesswork out of insurance for TMS. To learn more about insurance and TMS or to schedule a free TMS therapy consultation, please contact us online, or call or text us today at 877-257-3193.