Does Insurance Cover TMS?
TMS, or transcranial magnetic stimulation, is an effective deep brain stimulation technique that the FDA has approved TMS treatment for depression and OCD symptoms. For patients who are struggling with depression or OCD, medications don’t always work effectively. Thankfully, TMS is a viable option with minimal side effects, but finding insurance coverage for TMS may be difficult, though not impossible.
What does TMS treat?
Depression is one of the most common mental health disorders in the world. An estimated 7.1% of U.S. adults experience at least one major depressive episode in their lifetime. Although depression is debilitating and common, it is a treatable disorder. For mild cases, sometimes therapy and lifestyle changes alone are adequate. Moderate to severe cases of depression can be effectively treated with a combination of medications and therapy. Unfortunately, there are some patients who aren’t fully treated by medications alone. Left untreated, depression can be incredibly dangerous, increasing a person’s risk of self-harm and suicide.
Another mental health condition, OCD, happens to an estimated one in forty U.S. adults, or 2.3% of the population. OCD is incredibly disruptive to a person’s ability to function. Without treatment, people with the condition can become socially isolated and experience a poor quality of life. For many, medications and therapy can help.
Not everyone with OCD is a candidate for prescription drugs, so for both depression and OCD, TMS can work to alleviate symptoms and give patients relief when medications fail. Unlike other forms of deep brain stimulation, TMS is non-invasive and doesn’t require anesthesia or a surgical procedure.
Insurance for TMS
When anyone in the U.S. needs a medical procedure, a common question they ask is, “will my insurance cover it?” Unfortunately, it’s never a simple answer. Insurance companies are disjointed entities and what one company covers, another will deny. Knowing what is covered under insurance is critical for patients. Without knowing, they can end up with a large medical bill that may be difficult to pay.
Millions of people in the U.S. have insurance that will cover TMS treatment. Fortunately, health insurance companies are beginning to recognize the usefulness of TMS, but the amount of coverage for the treatment can vary for each provider. Some will cover it 100%, while others will only cover a portion of the cost. Coverage may also be assessed on a case-by-case basis.
The Affordable Care Act and TMS Treatment
Before the passage of the Affordable Care Act, or ACA, insurance companies were not required to offer mental healthcare coverage. They could also routinely deny patients coverage if the patient was diagnosed with a mental health disorder as a “pre-existing condition.” After the ACA passed, insurance companies were required to offer coverage for some mental health treatments, including TMS treatment.
Today, most major health insurance companies and networks will cover TMS treatment, including:
- United Healthcare
- Blue Cross Blue Shield
Also, keep in mind that coverage for TMS for Medicare and Medicaid may differ between states.
Does “in-network” and “out of network” change TMS coverage?
The contracting process between a TMS provider’s office and an insurance company is lengthy and complicated. If a TMS provider is considered “in-network,” it means that a patient’s insurance company and their doctor have agreed on reimbursement for treatments. “In-network” makes billing and authorizations much more comfortable to obtain since the insurance company and doctor’s office have already negotiated their terms. If a patient does not have “in-network” coverage, they can still be seen, depending on the policies of the TMS provider. However, it’s always easier to look for a TMS provider that is already “in-network.”
Does it take a long time to get authorization for treatment?
If a TMS provider’s office is in-network with a patient’s insurance company, then authorization for treatment won’t take very long. The TMS treatment center will submit a prospective patient’s pre-authorization immediately after the patient is evaluated for TMS treatment. After that, the time it takes for the insurance company to authorize the treatment will depend on several factors.
Most insurance companies that are in-network will only take five to seven business days to approve the procedure. In rare cases, it can take up to fifteen days. If a patient has out-of-network coverage, then a TMS provider may offer what’s called a “single case agreement” with the insurance company.
This is a form of negotiation with the insurance company to get them to authorize the coverage for an out-of-network procedure. Single case agreements can take a month or longer to reach authorization. The time it takes all depends on how cooperative and efficient the insurance company is. Depression is a serious illness, but in the insurance company’s eyes, TMS is not considered emergency treatment. A TMS doctor will do what they can to speed up the process of authorization with an insurance company.
How much of TMS treatment will an insurance company cover?
Every insurance plan is different, and coverage will vary depending on the plan someone has chosen. Some insurance policies will cover the entire course of TMS treatment. Others may require the patient to pay a copay or a deductible. Most insurance plans have some sort of deductible, and patients have to meet the deductible before insurance coverage starts. So until the deductible is met, every TMS visit would be paid for out of pocket. Also, some insurance plans combine mental health deductibles with medical deductibles, while others keep the two separate.
Once a deductible has been paid, then the insurance will offer a set percentage of the cost they cover, and some companies cover 100%. Others will require patients to cost-share. For example, an insurance plan covers 80% of TMS treatment after the deductible is met, and the patient has to pay the remaining 20%.
Are you wondering if your insurance will cover the cost of TMS treatment? Contact us at Pulse TMS today. We’ll go over your insurance benefits with you, so you’ll know exactly what’s covered.