Psychology services: your health plan must include them in its coverage

It is the psychology services coverage mandate in Puerto Rico’s health plans. Its practical effect is to close the door on the answer that the plan "only covers psychiatry": the law requires including psychology professionals’ services in the coverage, and describes broadly what those services encompass — from prevention and psychological evaluation to therapeutic intervention and consultation on intellectual, emotional, behavioral, interpersonal, family, social and occupational functioning.

People insured under insurance companies, health service organizations constituted under the Puerto Rico Insurance Code, or non-profit associations writing health service insurance in Puerto Rico. On the provider side, whoever renders the services must hold a current psychologist licence with no disciplinary actions, and meet the academic and professional credential criteria the law details.

• Being insured under an insurance company, a health service organization under the Insurance Code, or a non-profit association writing health insurance in Puerto Rico.Verified against the official source
• That the professional hold a current psychologist licence with no disciplinary actions under Act 96-1983.Verified against the official source

Information pending verification.

1. 1

   Step 1: Know psychology coverage is mandatory

   The law orders all insurance companies, health service organizations constituted under the Puerto Rico Insurance Code and non-profit associations writing health service insurance in Puerto Rico, to include in their coverage the services provided by doctoral-level psychology professionals trained by education, training and experience. It is not optional and does not depend on which plan you choose within those entities.

2. 2

   Step 2: Know which services are included

   The law describes them openly: psychology health services may include, but are not limited to, prevention, description or diagnosis of behavior, psychological evaluation, therapeutic intervention with psychological problems of varying severity, and consultation concerning the intellectual, emotional, behavioral, interpersonal, family, social and occupational functioning of individuals and groups. The phrase "not limited to" matters: the list is illustrative, not a ceiling.

3. 3

   Step 3: Check your psychologist’s licence

   Every person contracted by one of those companies to provide psychology health services must hold a current psychologist licence with no disciplinary actions, under Act 96-1983, known as the Act to Regulate the Practice of Psychology in Puerto Rico. It is a requirement that protects the patient as much as the profession.

4. 4

   Step 4: Know what training the law requires

   The professional must show documentary evidence — for example, a university transcript — of education, training and competencies in substantive areas developed through courses or didactic-practical experiences offered in a university psychology programme at master’s or doctoral level. Among those areas: foundations of psychology (biological, cognitive and affective, social and multicultural bases of behavior; growth and development across the life cycle; individual differences; history and systems); ethical, legal and professional issues; measurement, evaluation and diagnosis, including psychometrics, test development, administration, scoring and interpretation of psychological instruments and systems for describing or diagnosing behavioral disorders; and research methods and techniques and statistics.

5. 5

   Step 5: If coverage is denied, claim

   Refusing to cover a service the law mandates including is a coverage dispute. The forum for complaints against insurers is the Office of the Insurance Commissioner; if the matter concerns the Government Health Plan, the Health Insurance Administration contracts those plans. Ask for the denial in writing: it is what supports the claim.

Coverage is claimed first with your health plan. For complaints against insurers, the Office of the Insurance Commissioner. If the service you need is mental health in the public system, this site separately covers mental health rights and ASSMCA services.

• Accepting that "the plan only covers psychiatry": the law orders including psychology professionals’ services in the coverage.
• Believing the list of services is closed: the law says they may include, but are not limited to, those it enumerates.
• Not checking that the psychologist holds a current licence with no disciplinary actions, which is what the law requires for contracting.
• Thinking it only covers therapy: prevention, psychological evaluation, diagnosis of behavior and consultation are also included.
• Not requesting the denial in writing before going to the Insurance Commissioner.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov