Using Insurance for Therapy: A Simple Guide
Trying to understand insurance benefits can feel like reading a foreign language. Don’t let it discourage you from getting the mental health services you deserve.
Let’s start with some vocab
Premium: The amount you pay for your health insurance policy each month.
Premiums do not go towards your deductible or Out-of-pocket-max.
Deductible: A target amount you pay up to before your plan starts to chip in.
If you haven’t met your deductible you may pay the full amount for the service or a co-pay amount.
Coinsurance: The amount you pay for care after you have met your deductible.
May be a percent of amount paid in the deductible phase or a co-pay amount.
Copay: A set amount you pay for a service that is often much less than the full amount for the service.
Out of Pocket Max (OOPM): All copays, deductibles, and coinsurance payments usually go towards this limit.
Once you reach your OOPM, your plan pays 100% of care costs.
Depending on your plan you might pay a simple co-pay, have a deductible that needs to be met, or a combo of both. Unfortunately, there isn’t a one size fits all answer.
-
An in-network therapist has a contract with your insurance company.
That means:
The therapist agrees to a set rate determined by the insurance company
The therapist handles billing insurance directly
You typically:
Pay your portion (copay/coinsurance) at each session
Don’t need to submit claims yourself
-
An out-of-network therapist does not have a contract with your insurance company.
That means:
The therapist sets their own fee
Insurance may reimburse you for part of the cost
Whether you get reimbursed depends on your plan’s out-of-network benefits.
-
If you decide to use an out-of-network therapist, they may be able to provide you with a super bill. Think of it like a detailed receipt that you can submit to your insurance for possible reimbursement.
What Insurance Information Your Therapist Can (and Can’t) See
Folks tend to think therapy offices operate much like medical offices that can easily tell you the cost of service. I wish it were that simple! Since therapy practices are usually much smaller they typically do not have the infrastructure to support a dedicated billing team or advanced billing systems. Additionally, mental health benefits are tricky to find as they may be managed by a third party.
What therapists can often do:
Check to see if your plan is active
Check the status of claims they have already submitted
Sometimes contact insurance companies for general benefit information and support
What therapists usually can’t guarantee:
Your exact cost per session
Whether you have met your deductible
How your insurance company will process or reimburse claims
Changes to your benefits during the year
So What Can I Do To Prepare For Therapy?
Log in to your insurance providers portal.
Familiarize yourself with your copay/ deductible and OOPM structure.
Check for out-of-network benefits.
See if there is a cost estimator. Most therapists use billing codes 90791 and 90837.
Use the provider look up feature to see if they are in-network or out-of-network.
Review old claims to help you understand how it all works.
Ask your therapist for their cash pay rate and compare it to your benefits to see which is more cost effective.
Even a rough estimate can help you feel more prepared.
