Navigating health insurance can be overwhelming and confusing, even more so when you are dealing with depression. The last thing you want to do is worry about whether you’re covered or not, and letting that delay or prevent you from getting the treatment you need. We’re here to help!
Below is some additional information to help you understand coverage for TMS therapy, so you can coordinate treatment without concern over cost.
Because of its FDA clearance and proven efficacy, TMS therapy is now covered by most insurance providers. More than 300 million patients have policies that will cover TMS therapy, including Neurostar’s Advanced TMS Therapy.
It is important to know that while many insurance plans do include TMS therapy, coverage and payment can always vary based on patients’ specific plans and guidelines (and what state they live in). Some policies cover some of the cost of treatment, while others may cover the entire cost. Therefore we highly recommend that you contact your insurance company directly to verify eligibility, benefits, and coverage for TMS therapy. TMS clinics that you are considering may also help find out this information for you. Some examples of insurance providers that do cover TMS include but are not limited to:
When a doctor’s office or TMS clinic is “in network” with an insurance, it simply means that they have a special, pre-existing agreement on things like reimbursements and terms and conditions. This makes billing and authorizations much easier for the doctor’s office or clinic, and therefore much easier to get you started on treatment with no hassle. It does not mean that you cannot see “out of network” TMS clinics – many of them will still work with you – though it might come with a higher co-pay or a longer approval process. You can contact your insurance company or the TMS clinic itself to determine whether they are “in network” with your insurance plan.
Some insurance policies cover the entire cost of treatment, while others have what’s called a copay or deductible.
TMS clinics will typically have intake specialists who are well-versed in insurance plans and can speak with insurance companies on your behalf to understand your type of coverage. You can also contact your insurance provider directly to find out what your coverage for TMS is.
If you have a plan that has a deductible, you must meet the deductible before your insurance will start paying their portion. Until that deductible is met, all visits will be out of pocket. Some insurances combine the mental health deductible with the medical deductible, but not always. You might have a separate deductible for mental health services.
Once that deductible has been met, your insurance will have a fixed percentage of the cost that they cover. Sometimes they cover 100% after the deductible, but in some cases, you will have a copay (coinsurance). Coinsurance is essentially “patient responsibility” – you share the responsibility of paying for a portion of your treatment. For example, if your insurance covers 90% of the cost of treatment, your copay will be 10%.
Insurance companies consider each daily treatment an individual office visit. This means you will pay the copay each time you come to treatment. Most insurance companies authorize anywhere from 20-40 visits depending on their specific guidelines, so the total expenses paid by you will depend on the number of visits approved for your treatment.
Since TMS is considered a higher level of care, most insurance providers require that TMS clinics get a pre-authorization prior to starting treatment. This is different from a referral, and must be submitted directly to your insurance provider from the TMS clinic. When you select a TMS provider, they will usually schedule an initial consultation with you, where they ask you information about your medical history. This is the information that they will submit on your behalf to your insurance company.
Many insurance companies have guidelines that must be met before they authorize TMS treatment. Since TMS is approved for patients with treatment-resistant depression, patients most often must have a history of trying at least one kind of therapy (for example, cognitive behavioral therapy) and around 4 antidepressant medications. However, every insurance provider is different, so again, you should make sure to contact your insurance provider directly to understand any specific requirements they may have.
If you have chosen a TMS clinic that is in network with your insurance, it shouldn’t take very long. Most in-network providers determine approval within 5-7 business days. This processing time can vary, though, depending on the provider and depending on your medical history. Please note that TMS is not an emergency treatment, so if you are experiencing distress or a medical emergency, you should seek out help by visiting your doctor, going to an emergency room, or dialing 911.
This information is designed to help you understand the process of coordinating and paying for TMS therapy. As with all medical concerns, you should consult with your primary doctor and speak with your insurance provider to confirm any questions you may have. There are many insurance options that include coverage of TMS therapy, so it’s a treatment that many find to be affordable and cost-effective for their battle against Major Depression.