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How Do I Get Started Getting Insurance Coverage For TMS?


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Individuals exploring transcranial magnetic stimulation (TMS) as a treatment option can sometimes find themselves struggling to find out if TMS is covered by insurance. But getting TMS covered by your health insurance may not be as hard as you think. Although it is a relatively new therapy, TMS is gaining in popularity thanks to its high success rate in treating depression, and the FDA has approved the treatment for not only depression but for anxiety and obsessive-compulsive disorder (OCD) as well (1,2,).

Are you a candidate for TMS?

Still, not all insurance options are the same, and understanding the nuances of TMS insurance options, specific requirements, and potential pitfalls is paramount. 

Is TMS Covered By Insurance? Yes, But…

At Madison Avenue TMS & Psychiatry, we accept all major insurance plan that covers TMS. However, insurance coverage for TMS varies among providers. TMS is typically used to treat depression, but many insurers also cover it for other mood disorders. Some well-known insurers like Medicare, United Healthcare, Oxford, Aetna, and Cigna offer coverage for TMS, but the extent and conditions may differ—for example, Cigna will cover TMS for OCD as well as depression, whereas others will cover it for depression only. It’s crucial to review your policy or contact your insurance provider to understand the specifics of your coverage before booking your treatment. You can check our list of in-network insurance providers that explicitly partner with Madison Avenue TMS & Psychiatry, but even if you don’t see your provider there, we can easily negotiate an out-of-network agreement with your provider to partially or fully cover your treatment with us.

HealthFirst: The Medicaid Option For TMS

For those covered under Medicaid, HealthFirst stands as the sole Medicaid plan that covers TMS in New York. While Medicaid plans often have stringent requirements, HealthFirst has recognized the efficacy of TMS in mental health treatment, offering an opportunity for patients on Medicaid seeking this innovative therapy.

Navigating The Application Process

Understanding the ins and outs of the insurance application process is vital. For the smoothest experience, it’s recommended to be proactive and follow these steps:

  1. First contact: Start by contacting Madison Avenue TMS & Psychiatry online or calling us at (212) 731-2033. In our first conversation, we will gather the necessary medical information and help you through every step of the process. 
  2. Gaining prior authorization: Typically, insurance companies require documentation to establish the medical necessity of TMS and a justification for the costs. For example, TMS is only usually authorized for depression if you can prove that you have previously tried at least four antidepressants out of at least two major drug classes and have been unsuccessful in fully alleviating your symptoms. Madison Avenue TMS & Psychiatry can submit the necessary paperwork to your insurer and negotiate the costs.
  3. Confirming coverage: Coverage will either be under your existing plan, or we can negotiate a single-case agreement with your provider to maximize coverage and keep your out-of-pocket costs down.
  4. Starting treatment: We will book your first appointment and get you started on TMS therapy.

For more information on single-case agreements and prior authorizations, see our published guide. If you have any further questions, we will be happy to clear things up via call or email.

Understanding The Deductible Threshold

Understanding the deductible threshold in health insurance is crucial in managing out-of-pocket expenses. The deductible is the amount you must pay out of pocket before your insurance begins covering the costs (2). 

For example, if your health insurance plan has a $1,000 deductible, you are responsible for paying the first $1,000 of covered medical expenses out of your own pocket. Once you have paid the deductible, then the insurance company will start to contribute—depending on your insurer, this could mean covering 100% of the cost of TMS therapy. However, some insurers will still require patients to co-pay after the deductible, e.g., you might have a plan that covers 90% of TMS treatment (after the deductible has been paid) and then have to pay the remaining 10%. 

Are you ready to try TMS?

In many plans, the deductible is a specified dollar amount that resets annually. To minimize financial burden, patients are encouraged to submit proof of spending within the current insurance budget year, potentially avoiding deductibles in the following year.

Madison Avenue TMS & Psychiatry: Finding A Payment That Works For You

For those considering TMS as a self-pay option, Madison Avenue TMS & Psychiatry offers competitive prices for cash payments. This can be an appealing alternative for individuals without comprehensive insurance coverage or facing coverage limitations. Everyone deserves good mental health, and our commitment to accessible mental health care means that we work hard to ensure that cost is not a barrier to treatment.

If you have any questions regarding the cost of TMS treatment in New York City or about insurance coverage for TMS, contact us online or call our office at (212) 731-2033.

Resources:

  1. FDA clears brainsway Deep TMS system for decreasing anxiety symptoms in depressed patients. National Institute of Mental Health. Brainsway. August 18, 2021. Link. Accessed November 24, 2023.
  2. FDA permits marketing of transcranial magnetic stimulation for treatment of obsessive compulsive disorder. U.S. Food & Drug Administration. Updated August 17, 2018. Link. Accessed November 24, 2023.
  3. Health Insurance Deductible: What It Is and How It Works. Investopedia.com. Updated January 02, 2023. Link. Accessed November 24, 2023.
Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.


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