Postpartum depression: the screening you are owed and the coverage your plan must give

It is the law that turns postpartum depression screening into something the system must offer and the plan must cover, instead of depending on someone happening to ask. It has two useful parts: a detection protocol the Department of Health must implement, and a coverage mandate that reaches even the Government Health Plan.

Mothers who suffer postpartum depression, are at risk of suffering it, or show associated indicators. For coverage, the text reaches mothers showing symptoms of prepartum or postpartum depression, or who are identified or referred to emotional health professionals or institutions as patients at risk of suffering it.

• Showing symptoms of prepartum or postpartum depression, or being identified or referred to an emotional health professional or institution as a patient at risk of suffering it.Verified against the official source

Information pending verification.

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   Step 1: The coverage is not only “postpartum”

   Worth reading slowly because it changes what you can ask for: plans shall expressly cover the screening and the physical and emotional treatment of mothers showing symptoms of “prepartum or postpartum” depression. The mandate starts before birth, not after.

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   Step 2: Which plans it reaches

   The list is long on purpose: every insurer and health service organization organized under the Puerto Rico Insurance Code, insurance plans providing services in Puerto Rico, any other entity contracted to offer health benefits in Puerto Rico, “as well as the Government Health Plan.” And the duty covers all their products, plans or premiums. The provision also applies to entities excluded under Article 1.070 of the Insurance Code, which are overseen by the Department of Health.

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   Step 3: Screening starts in the first month of pregnancy

   The Department of Health regulation must set a screening instrument or uniform examination routinely serving as a mechanism for early detection of depression symptoms in prenatal stages. That instrument “may be self-administered or may be administered to every mother by a health professional duly authorized by their respective Examining Boards, during gestation, starting the first month of pregnancy, and repeated at the end of each trimester.”

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   Step 4: Where the screening can happen

   The law leaves the timing to the regulation, and names the settings: the hospital environment, in interaction with nursing, social work, counseling or lactation consulting professionals; mothers’ postpartum visits to their primary physicians; babies’ postnatal pediatric visits; or any other suitable moment. The baby’s pediatric appointment is one of the places the law expressly names.

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   Step 5: The referral leads to voluntary evaluation

   The word is in the text and worth knowing: every mother showing symptoms after screening or observation shall be referred to a mental health professional so that, “voluntarily,” the corresponding evaluations are performed and appropriate treatment provided if so recommended. The referral does not bind you; the coverage is what is bound to be there.

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   Step 6: If the plan denies it

   The law provides a consequence: non-compliance with the coverage article’s requirements may carry administrative fines under Act 72-1993, known as the Puerto Rico Health Insurance Administration Act, as well as under the Puerto Rico Insurance Code, or any other special law with competence. The claim route is that of a denied benefit, which we cover in the health insurance guides and in the Patient Advocate Office guide.

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   Step 7: This law prevails over any that do not harmonize

   It has a supremacy clause: this law’s provisions shall prevail over any other legal provision, regulation or rule not in harmony with them. That is useful when someone answers you with an internal plan rule.

The Department of Health develops the preventive protocol and the regulation, and oversees the entities excluded from the Insurance Code. If the plan denies you screening or treatment, the claim goes through the denied-benefit route: the Office of the Insurance Commissioner and the Office of the Patient Advocate. If you need help now, ASSMCA’s PAS line has its own guide and is the correct destination.

• Asking for coverage only after birth: the text says “prepartum or postpartum” depression.
• Assuming the Government Health Plan is outside: the law names it expressly.
• Believing screening is a one-time thing: the instrument is repeated at the end of each trimester of pregnancy.
• Not asking for it at the baby’s pediatric appointment: it is one of the settings the law names.
• Reading the referral as mandatory: evaluation and treatment are done voluntarily.
• Expecting zero out of pocket: the law preserves reasonable and lawful deductibles.

These are the government pages this guide is based on.

• Departamento de Salud de Puerto Rico

  Salud

  bvirtualogp.pr.gov

• Department of Health

  Departamento de Salud

  www.salud.pr.gov