BENEFITS

IS MENTAL HEALTH COVERED BY INSURANCE?

Understanding In-Network Vs. Out-of-Network Benefits

Unfortunately our healthcare insurance system doesn’t make it easy to understand what you might end up paying for therapy. While this can really feel overwhelming and make your head spin, I can help you make some sense of estimate the cost of your care.

The first thing to know is what mental health coverage your policy offers. You can get an estimate of your costs to see me by calling the member number on the back of your insurance card.

Here are the questions you should ask to learn about your mental health benefits:

Does my insurance policy offer in-network mental health benefits?
If the answer is ‘yes,’ you can see any therapist in your insurance companies network with your plan. For example, if you have United Healthcare, you can see a providers takes United insurance.
In-network tends to be more affordable than out-of-network with some exceptions… In-network providers have agreed to accept a discounted rate for services in exchange for being part of the insurance company’s network. However, you’ll need to understand more about your policy to ensure this is the more affordable option…
What is my in-network deductible and how much of it has been met?
A deductible is a predetermined amount of money that you will need to pay out of pocket before your insurance coverage kicks in. Deductibles serve as a form of cost-sharing between the insured and the insurer, and help lower insurance premiums by shifting some of the financial responsibility onto the insured.
For example, if you have a $8000 deductible on your insurance policy, you will need to pay a total of $8000 before the insurance company would cover any costs.
What is my copay?
Once your deductible has been met, you are responsible to pay a set amount called a copayment or copay. Copays are typically lower than the full cost of a service, serving as a cost-sharing mechanism between the insured and the insurance provider. They streamline the payment process and provide predictability for patients, ensuring access to healthcare services while helping to manage healthcare costs for both parties involved.
So once you’ve paid down your $8000 deductible, your appointments will be a set price- usually between $25-$100 per session.
Does my insurance policy offer out-of network mental health benefits?
Out-of-network benefits refer to the coverage provided by an insurance plan for services received from providers not within the insurer's approved network. While in-network services may offer lower costs, out-of-network benefits extend coverage beyond these boundaries and in some cases with a higher out-of-pocket expense. Out-of-network benefits extend coverage beyond these boundaries, enable individuals to seek medical care from a broader range of providers, offering flexibility, and access to specialized services. A plan that includes out-of-network benefits is usually referred to as Preferred Provider Organization Plan (PPO) or Point-Of-Service Plan (POS).
Out-of-network therapists charge between $120-$500 per session.
What is my out-of network deductible and how much of it has been met?
Just like the in-network deductible, there is typically a separate deductible for out-of-network benefits.
Out-of-network deductibles can range from $100-$10,000/year. So for example, if your deductible is $8000 and your therapy sessions are $200/session, you would be responsible to pay the full rate of $200 for 40 sessions before receiving any reimbursement from your insurance company.
What is the co-insurance amount?
Coinsurance is a cost-sharing between you and your insurance provider, where both parties pay a percentage of covered medical expenses after the deductible has been met. Coinsurance helps distribute financial responsibility, encourages cost-conscious healthcare decisions, and can lower insurance premiums.
For instance, after you’ve paid your $8000 deductible, your co-insurance ranges between 20%-40% of the $200 session costs, you will be reimbursed between $120-$160/session by your insurance company.
What is the allowable amount covered for outpatient psychotherapy (CPT code 90847)?
So here’s the biggest catch to figuring out what you may need to pay for therapy- Insurance companies do not reimburse just any old cost that your therapist charges. They will cover an amount of what they deem is acceptable for a therapy session- otherwise referred to as the “allowable rate.” Each plan in each insurance company “allows” a different amount.
The typical allowable rate ranges from $60-$250 per session, with the average being $180 per session. This means that if your co-insurance is 30%, your insurance company will reimburse you 70% of $180 (the allowed amount), even if your therapist charges $200/session. Therefore you would be responsible to pay $126 pers session.

So you’ve got some math to do once you have all the facts and figures of your insurance policy. Beyond the calculations, here are some facts you should consider in your search for a provider regarding the use of your in-network vs. out-of-network insurance benefits:

In and out-of-network costs are pretty similar. If you do the math (here’s help- I hate math, too), there’s not much difference between paying in and out-of-network therapists. It’s a different process that is now been made pretty simple to manage online.

A high deductible shouldn’t deter your search. If you have a high deductible ($5,000+) and don’t have many other medical expenses, you are responsible for paying the full amount of your deductible before your standard copay applies. Therefore in-network therapists and out-of-network therapists can accrue effectively the same cost.

Your insurance may limit your search for specific expertise. You’re looking for a therapist with a unique skill set. Private pay therapists often have more experience and specialized practices. If you imagine working with someone focused on niche expertise, those therapists often do not take insurance.

Good out-of-network benefits Many out-of-network benefits reimburse you as much as 80% of each session fee. Depending on your plan and the therapist’s rate, using your out-of-network benefits may be more affordable or comparable to your copay to see an in-network therapist.

Credit card benefits If you have a credit card that offers points or miles, you will receive more charging the full fee of your care. If you process your reimbursement immediately, you should receive a check in time to pay off your credit card.

More immediate care It can be very difficult to find a therapist who is in-network and accepting new clients, especially for the less-known insurance plans. If you limit your search by insurance, you may have to spend months on a waitlist before seeing a therapist.

Using insurance may limit your care. When billing an insurance company, therapists are constrained by only providing services they can bill. Out-of-network therapists can offer more personalized, longer, more frequent, and/or out-of-the-box treatment than insurance might cover.

Considering all the reasons mentioned above (and more), I would be happy to provide documentation for reimbursable services if your insurance plan provides out-of-network benefits.

Please be sure to contact your insurance company prior to your first session to understand your financial responsibility and commitment. If you have any questions about how much your insurance company will reimburse you for my services, email me at Laura.Geftman@gmail.com.