Insurance and Therapy

Insurance is a confusing world. Things are constantly changing, there is so much jargon, and it’s just generally hard to know what’s what. In this post I hope to clarify some of the details of how you can use your insurance when receiving mental health therapy.

Insurance Basics

Insurance company – This usually refers to the company that you pay to provide you with insurance coverage. Some larger companies are Blue Cross Blue Shield, Medicare, Aetna, United Health Care, etc.

Insurance plan – Insurance companies offer different packages, or “plans” that you can buy. This refers to a set of agreements about how much your insurance will pay for a medical service vs. how much you will pay as the patient. When you buy a plan, you agree to amounts that both you and the company will pay for a certain type of medical care.

Benefits – Insurance “benefits” are the specifics of the agreement about who pays what, based on the plan you have. Some plans will include “benefits” for mental health services, meaning they are “covered” and that the insurance will help you pay for them. In some plans, mental health benefits are not covered, meaning you will be responsible for paying the doctor or therapist out-of-pocket even if you have coverage for different types of medical care.

How do I know if I have benefits and coverage for mental health? This usually involves you contacting your insurance company. Some companies will have that information available on their websites or have automated recordings that can read you your benefits over the phone. You can call the number on the back of your insurance card, and inquire about “Benefits and Coverage”, or some other phrasing that includes one or both of those words. You will usually need your member ID number to receive this info, which is also on your card. If you don’t have your member ID number, a representative can usually help you over the phone.

When you receive your benefits information, you will want to look and see what types of mental health services are covered. Some insurances use the term Behavioral Health, which includes mental health benefits. Outpatient services are what we think of as traditional appointments, going for 20-60 minutes at a time and talking to a therapist or doctor. The type of service that I provide is usually called something like Outpatient Psychotherapy, Outpatient Cognitive Behavioral Therapy, (or something similar to that) which refers to sessions that are normally 45-60-minutes at a time. “Outpatient psychiatry” refers to seeing a psychiatrist for medication management, in which you make a 20-30 minute appointment and see a medical doctor (which I am not). “Inpatient services” typically refers to being hospitalized in a psychiatric inpatient unit in a hospital for mental health. (FYI “inpatient” often means something a little bit different for substance abuse treatment.)

In-Network and Out-of-Network Providers

Now it’s time to find an actual therapist who your insurance will help pay for.

Provider – This just means a medical professional or agency, who are “providing” your medical treatment. This is an umbrella term for therapists, doctors, hospitals, etc.

In-Network – If a provider is “in-network”, this means that they have their own agreement with the insurance company about how much they will be paid for a service. Other ways to say this are that the provider is “paneled”, “credentialed”, or “contracted” with the insurance company. The amount that the provider makes for this service with you is chosen by the insurance company, not the therapist. You can see this provider and pay the amount that your insurance plan agreed to cover under the type of plan you have. This usually involves you paying either a co-pay, co-insurance, or the “contracted rate” until your deductible is met. (Did I lose you??) If a therapist is in-network with your insurance, they should not be charging you more than what the insurance company says they should.

Out-of-Network – If a provider is out of network, this means they do not have any sort of contract with the insurance company. However, some insurance plans have “out of network benefits”, meaning they can help pay for a service with a provider even if the provider isn’t contracted with them. Again, you would have to check your benefits and coverage to see if you have any out of network mental health benefits.

Pros and Cons to Using Out-of-Network Benefits

Pros

You have the option to see a therapist that you really like, and have the services at least partially covered, if the therapist is willing to go this route.
If you have a high deductible, you may end up paying less out of pocket if the therapist’s individual rate is less than the contracted rate your insurance company pays an in-network therapist.

Cons

Out of network benefits generally don’t go toward your deductible.
In some cases, you may be paying more out of pocket than you would with an in-network provider.
It can mean a little more work on your end depending on how the therapist handles it.

Different providers will handle out of network benefits differently. Some don’t take them at all. The way I do it is to charge my clients my out-of-pocket rate ($180), then provide them with something called a “superbill”. A superbill is a document that has all the information needed to submit a claim to an insurance company (a claim is basically a form that tells the insurance company you had a medical service and payment needs to happen). My clients use the superbill by submitting it with a claim form directly to the insurance company. This way they can get reimbursed from the insurance company after the session and get some of that $180 back. I am happy to help my clients fill out the claim forms until they can do it for themselves.

Hopefully this has shed a little light on the way things work with insurance. I am more than happy to help my clients navigate this as we start working together!

Laurel Mallonee LCSW