Can I Use My Health Insurance for Psychotherapy?
With the new year upon us, many people are finding themselves with questions about deductibles, new insurance plans and how to find in network care. Sometimes finding in network care for therapy can be tricky, as different plans have different levels of coverage and different requirements for eligibility. Read more below for a quick rundown of what you need to know if you plan to use insurance for psychotherapy.
What is the difference between an in network and out of network provider?
An in-network provider means that the therapist has contracted with your insurance company to see patients at an agreed upon rate. This means when you see an in-network provider your insurance company will pay the therapist directly (once you’ve hit your in-network deductible if you have one) and you will likely pay a co-pay.
Not every in-network plan is the same, one person with an Aetna plan may only pay a $30 co-pay per session while someone else pays the full session fee, why? Because different plans have different levels of coverage. If you chose a plan with a deductible, you are typically responsible for the full fee for many types of medical services until the deductible has been met. Once the deductible is met, your insurance will begin to cover the sessions, and depending on the plan, you’ll may still owe a co-pay or pay a percentage of the session fee (co-insurance).
What is an in network deductible?
Your in-network deductible is the amount that you need to pay for any medical care or services before insurance begins to pay for treatment. Payment for out of network providers or services will not count towards your in-network deductible. Deductibles often re-set in January.
What are out of network benefits?
Many plans have a higher out of network deductible, but still offer coverage for services once that deductible has been met. Out of network benefits for therapy mean that once you hit your out of network deductible, your insurance company will reimburse you directly for therapy sessions. This is different than in network, because you’ll still pay the therapist their fee directly, and submit a superbill to your insurance company. Once the superbill is approved, the insurance company will send you payment for the full session fee or part of the fee.
Example: Mark has a plan that has a $1700 in network deductible and a $3000 out of network deductible. Once he meets the deductible, he will be responsible for 10% co-insurance
If Mark sees an in-network therapist:
He will pay the full session fee $150 until his deductible is met. Remember, this includes all in-network care, such as doctor appointments, so he may hit his deductible fairly quickly. Once he’s passed the $1700 threshold, his benefits will kick in and he will pay $15 per session.
If Mark sees an out of network therapist:
Mark will pay the therapist directly their full fee of $150 a session. The therapist may supply Mark with a superbill that he will submit to his insurance company. Once he’s hit his out of network deductible of $3000, he will continue to pay the therapist the full fee, but now his insurance company will begin to send him reimbursements for sessions upon approving the superbills.
What about couples therapy?
Couples therapy uses a different code and model when billing to insurance. There is one “identified patient” who must qualify for treatment with a valid mental health diagnosis, and that treatment can include couples therapy. The treatment will use the insurance of only the identified patient. Not every plan will cover couples therapy treatment, even if they cover individual psychotherapy. This is why it’s important to call your insurance company and ask if they cover couples sessions specifically.
What do I say when I call my insurance company?
If you’re still confused about what to expect for payment, it’s always best to check directly with your insurance provider. You can usually call the number on your health insurance card to speak with a representative.
Below is a script for inquiring about coverage for therapy:
“I’d like to work with an in-network provider for therapy.
Do I have an in-network deductible? Have I met it?
Do I have coverage for therapy? More specifically,
what can I expect to pay for an intake session? The CPT code is 90791
What can I expect to pay for a follow up session? The CPT code is 90837
Do I have coverage for couples therapy, if so, what can I expect to pay for a couples therapy session? The CPT code is 90847”
For out of network care:
“Do I have an out of network deductible? Have I met it?
Do I have out of network benefits?
What are the reimbursement rates (for the CPT codes listed above)?”
Why do so many therapists not take insurance?
The answer to this question is complicated, but frequently has to do with reimbursement rates and stringent requirements from insurance companies. While making therapy accessible is important to many therapists, there are drawbacks to taking insurance. Sometimes issues with insurance can result in more work and stress for therapists who prefer to focus on providing clients with good and ethical care. It can be difficult to find an in network provider, especially in places where options are limited. Some clients may opt for an out of network provider and choose to pay a higher rate for services because of the therapist’s specialties or fit. Ultimately, it depends on your personal preferences and financial resources.
What to consider when picking your health insurance plan
Most people get their health insurance through their employer, meaning they may not get a choice in which insurer they have, but can select from multiple types of plans offering different levels of coverage. Oftentimes people select a cheaper plan, not realizing that it may mean a higher deductible or higher co-pays for treatment. If you plan on using your insurance for therapy or expect to have other costly or regular appointments for healthcare, it may make sense to choose a plan that includes better coverage or lower deductibles for in network and out of network care. When selecting a plan, be sure to look through the packet explaining benefits thoroughly, and call and ask the insurance company or your HR representative if you have any questions about plan selection.