What Happens if I Were to Surpass Insurance Coverage?

After many hospitalizations last year (sophomore in college), I was told while in -patient that my insurance was not going to cover anymore hospitalizations, but rather would send me to a residential facility. I was told it would be a court order and I was forced to choose between ECT and residential, though I believe the staff and doctor was manipulating the situation to coerce me into doing ECT.

Since then I have changed insurance and have had many ER trips, one over night observation, and a partial program, and one hospitalization. The insurance covers the one productive hospital in a thirty mile radius.

I do not know much about insurance or my current policy, what would happen if I were to reach the amount allotted for coverage? Would that be means to actually send me to residential based on being labeled as a threat to myself?

I am just trying to understand the situation last year and the fear that one day I would be forced into a residential program.
Currently I owe more than twice the amount in medical bills than I do in full-time college tuition.

Hi, Kahnecht, welcome to PsychCentral (PC).

I think you have to call your insurance company and ask about your coverage, what companies cover and for how much, etc. varies depending on what you have. My guess though would be if you were to surpass what is paid for then there would be no more coverage for that year/period but since you would still need care, you'd go into a "state"-care facility which would probably be residential, since you would not be able to care for yourself and would not have any other resources. It would be a bit like not being able to pay rent on a place, not having any money and becoming homeless and then staying in a homeless shelter. Even for physical illness, hospitals are only for acute care, when you don't need hospitalization anymore, are stable or recovering, then they move you to a care facility. That's what the residential place would be for/like. If you cannot get well in a hospital, if it is going to take longer, then you need a longer care facility.

I'm sorry you have been struggling so much with it all.

As Perna said, you would have to consult your insurance company.

I had a similar situation a few years ago in which they tried to force me into ECT via court order but could not get enough PDocs to agree to take it before a judge. I was the one advocating for an appropriate treatment center instead of ECT though. The PDoc was pushing the ECT. I had been in and out of general psych hospitals 30+ times over a period of a year and a half (most were in the final 6 months. I would go in for a week or more, come out for a few days, and be sent back in). Between hospitalizations, I was in a PHP or IOP program while also going to individual therapy 2-3 times a week. Both the doctors and my insurance were getting frustrated and scared. Honestly, so was I. They were finally able to find an acute trauma program that had space and could take me. I was actually hoping for a longer, more productive stay, but I was there for 2 weeks and it helped a lot.

With the new mental health parity that has gone into effect in the US, insurance companies are required to cover mental health needs to the same level they do physical needs. You have every right to advocate for more appropriate treatment. If you are having specific issues (for me it was trauma-related), and you think a specialized program would help, by all means, push for that. General psych hospitals are good for acute stabalization, but they offer nothing in terms of actual treatment.

Also, the term "residential treatment" tends to mean simply a longer stay at a more specialized facility. For example, most eating disorders programs are residential, as are most substance abuse treatment centers. They typically provide actual therapy and focused treatment vs. pumping you full of meds and keeping you physically safe. They are also generally time-limited. Most average 30-60 days, so while it is definitely more long-term than a psych hold, it's not all that long in the grand scheme of things. There are certainly longer-term residential facilities, but the average program for most issues is still much less than 6 months...

If you are faced with that again, I would suggest asking for a clarification on the type of residential program they are suggesting, and if possible, advocate for them finding a program that would actually help rather than simply warehouse you. There are many programs across the country. In my expereince, if your insurance company wants to cut down on what they pay for treatment, they will often authorize a facility they don't normally cover if it means you will stop utilizing the really high-priced emergency facilities.

I would also suggest asking if the insurance company offers "case management" services or something along the lines of an advocate. I had one with my prior insurance (the one that specially authorized the trauma program a few years ago). She was a great help in pushing treatment authorizations through, and holding off on treatment I was staunchly against (the ECT... though she did spend several phone calls trying to convince me to go along with the doctors on that one, she also later agreed to push for payment of any specialized program the hospital could get me into). I have one with my new insurance also. I have yet to use her, but it's nice to know I can call her with questions and concerns.

Good luck, though I hope you never have to have that experience again. It can be quite traumatizing...