Enforcing Your Mental Health Copay Cap: Don’t Overpay!
Your contract guarantees an annual maximum in copays you can be charged for mental health and substance use care. Beginning January 1, 2024 through plan year 2026, that maximum is $450 per individual and $900 per family. Note that the $450 per individual cap applies to both you and enrolled dependents.
GEO has received reports that GradCare plan users are being charged beyond the cap. We recommend that you proactively check your billing to ensure that you are not getting charged in violation of the rights in your GEO contract.
To check your total annual mental health copays:
- Log into your online account (or create an account if you haven’t yet) at member.bcbsm.com
- In the menu at the top, go to Claims > Claims
- For each claim related to mental health care, add up the copays listed in the “You pay” column at the far right of the table. Note that you can filter your claims by provider in the menu at the left to make it easier to calculate only mental health care coverage. It should automatically filter by current year; you can also set the filter to other years.
If you find that you are being charged beyond the annual maximum:
- Ensure you don’t overpay: Call BlueCross BlueShield at 800-658-8878 to request a cancellation of any incorrect copay charges in excess of the $450 individual/$900 family maximum. You should have your GradCare member number, which you can find on your GradCare ID card, and the Explanation of Benefits document for the incorrect charges handy, which you can access at member.bcbsm.com under Claims > Explanation of Benefits (EOB).
- It may be helpful to use this language from the current GradCare Certificate of Coverage: “A $500 per member/ $1,000 per contract annual copayment maximum applies to all three Levels combined for Outpatient Mental Health and Outpatient Substance Use office visits, no matter the location” (pp.59-60).
- Fight to eliminate mental health copays altogether! Grad workers are negotiating our next contract with the University, with a platform that includes crucial healthcare improvements like bringing the mental health copay caps down to $0. This would not only save grad workers money, but it would simplify mental healthcare to avoid the need for webpages like this one!
When will I hit my copay cap?
- If you see a therapist once a week and pay a $25 copay at each appointment, you will reach the $450 individual copay cap after 18 weeks. OR if two members of your family each see a therapist once a week and pay a $25 copay at each appointment, you will reach the $900 family copay cap after 18 weeks. This means that if your first appointment is the week of January 2, 2023, then you should not pay for appointments after the week of May 1, 2023.
- If you see a therapist twice a week and pay a $25 copay at each appointment, you will reach the $450 individual copay cap after 9 weeks. This means that if your first appointment is the week of January 2, 2023, then you should not pay for appointments after the week of Febuary 27, 2023.
What kinds of care count towards the copay cap?
According to BlueCross BlueShield: “A $450 per member/ $900 annual copayment maximum applies to all three Levels combined for Outpatient Mental Health and Outpatient Substance Use office visits, no matter the location.”
This includes testing and diagnostic services; therapy and counseling in an individual, group, family, or couples setting; and alcohol or drug detoxification, all conducted in an outpatient setting, i.e. where you are on a short-term office visit and not spending the night. Some residential or semi-residential mental health and substance abuse programs may also be included under outpatient care — you should contact BlueCross BlueShield to determine whether a specific type of care counts toward the copay cap.
The coverage levels refer to whether the provider is out of the GradCare coverage area, i.e. if you have accessed mental health care while traveling for the short or long term. In other words, you should pay a maximum of $450 individual / $900 family for mental health care in calendar year 2023, no matter the location of the provider.
You can find more information in your GradCare Certificate of Coverage document, which you can access at member.bcbsm.com under My Coverage > Medical > Plan Documents.