UNTANGLING THE QUAGMIRE OF INSURANCE COVERAGE FOR COUNSELING
by Patti F Boyle
This is about how we pay for therapy, or, rather, how medical insurance pays for some therapy, sometimes. I know, boring topic. So, out of consideration, I’ll be as brief as possible. In fact, I am prefacing with “highlights” so you can skip reading the big part if you want.
1. If you use your insurance for payment or reimbursement for therapy, you will have a mental health diagnosis on your medical record.
2. The amount you must pay out-of-pocket before insurance benefits kick-in is called the deductible. Deductibles can be as high as $10k, so check with your insurer so you know what your deductible is.
3. Insurance plans may also require you to “co-pay”, or share medical expenses, for each appointment you have with a medical provider or a therapist. Check with your insurer about co-pays as well.
4. If you paid your deductible and want to use your insurance benefits, and you want your therapist to bill your insurance directly (so you pay nothing at the time of your appointment), you need to choose a therapist who is “in-network” with your insurance provider.
5. An “in-network” therapist is a professional who has signed a contract with your insurance provider.
6. An “out-of-network” therapist has chosen not to contract with insurance providers.
7. The fee for “out-of-network” therapy is often reimbursed by insurance.
8. If you are looking for couple/marriage counseling, it is usually not covered by insurance. This can be true for family counseling as well. Again, check with your insurance provider and your therapist.
9. In general, always call your insurance provider to ask questions about your coverage, and do it at least twice to make sure each representative is giving you the same information (there is a lot of confusion and misinformation in the medical insurance world), and talk to your therapist about insurance as well.
To begin with, all health insurance plans must include mental health benefits, and to qualify for insurance payment, the “patient” must be diagnosed with a mental health disorder.
For many people, having a mental health diagnosis is of no concern, but for professional or personal reasons, it can be a concern; therefore, please know that if you use your insurance for payment or reimbursement for therapy, you will have a mental health diagnosis on your permanent medical record.
While all medical insurance plans must include mental health benefits, these benefits will vary depending on the plan. Most insurance plans require we pay a set amount of out-of-pocket cash before insurance benefits or payments kick in. The amount we must pay out-of-pocket before our benefits kick in is called the deductible.
Deductibles can be as high as $10k, so check with your insurer so you know what your deductible is. Please note that your therapist will not know what your deductible is or if you have reached it. If you haven’t paid your deductible and your therapist bills your insurance for payment, your therapist will not be paid by insurance and will send a bill to you.
In addition, some insurance plans require a “co-pay”, which means they want you to pay for part of your healthcare when you visit a professional for an appointment. Co-pays can range from less than $20 to more than $60, or are a percentage of the total fee for the appointment. When you call your insurance about your deductible, ask about co-pays too.
Once you paid your deductible and have decided to find a therapist who accepts and bills your insurance, you will need to look for an “in-network” therapist. A contracted or “in-network” therapist refers to a health care professional who has agreed to certain terms mandated by an insurance company and has signed a legal binding contract; in essence, an “in network” provider is employed by the insurance company. This also means your diagnosis and the therapist’s notes about you become available to your insurer and any insurance employee who lays eyes on your record, and that a representative from your insurance company has the right to drop-in on your therapy session for the purpose of ensuring quality care. Of course, this rarely occurs, but contracted therapists are required to give insurance companies these rights. Again, for some this is of no concern, for others it can be a concern.
An “out-of-network” therapist has decided that being bound to an insurance contract is not beneficial, and they opt-out. But working with an “out of network” therapist does not mean your insurance will not pay, at least in part, for your visits. There is a good chance it will, but you will need to make a claim for reimbursement (more on this topic below). If you choose to make a claim for reimbursement, your diagnosis and therapy notes become available to your insurance company; if you do not choose to make a reimbursement claim, your diagnosis, therapy notes and therapy sessions stay exclusive to you and your therapist.
“In” and “out” of network therapists are both credentialed and licensed. On insurance websites, insurance companies often speak to the high quality of their providers, including therapists, but the vetting process is basic and involves ensuring the therapist is licensed and has no criminal record or serious complaint lodged with the Department of Health. There is no interview or series of serious and significant questions in which to respond, and to become an “in network” provider, a therapist simply agrees to the contract being offered. In some cases, therapists are willing to contract with insurance companies, but the insurance company has closed its “panels” because it is thought there are plenty of “in-network” therapists; thus, some therapists who want to be “in-network” are kept “out”. Whatever the case, rest assured that “in” and “out” of network therapists are equal in terms of general qualifications
If you want to know if a therapist is “in” or “out” of network, contact your insurance provider, either online or by phone (the number is often listed on the back of your insurance card); however, be aware that provider lists are not always updated, and your best bet is to speak to your chosen therapist for accuracy.
As noted earlier, when you choose to work with an “out-of-network” therapist, there is a good chance you can get reimbursed for the cash money you pay out-of-pocket, but you may have to wait a few weeks to get your cash back. Again, to be brief, I have listed the process:
1) You pay your therapist their fee upfront; 2) The therapist gives you a statement or “superbill” that has all the various numbers and number codes that insurance companies want to see (including your diagnosis); 3) You fill out a “claim form” (most likely this is an online task), and submit it; 4) You wait for your reimbursement.
Generally, paying an “out-of-network” therapist and making a claim for reimbursement is pretty straight forward and there is no mystery around how much therapy will cost. The trouble is we are required to do the work of actually making a claim, and, remember, once we do make a claim we give our insurer the right to our therapy records.
All of the above applies to people who work with a therapist one-to-one, or to those seeking substance abuse treatment, or for hospitalization. All of the above does not apply to people seeking marriage/couple counseling or family counseling. Although some insurance plans cover family counseling, few, if any, include couple or marriage counseling. There are certain circumstances that would allow for therapists to use a billing “code” that may generate insurance payment, and if you want to know more about these circumstances, please ask a therapist.
In good faith, the Affordable Care Act mandated that mental health services be included with medical insurance, but accessing coverage for counseling has become yet another quagmire to untangle. It is frustrating to search for a therapist only to find the insurance benefit you thought you had does not apply, or to seek an in-network therapist only to find they are all full, and to find out later you could have chosen an out-of-network therapist had you known the possibility of reimbursement. And perhaps the most upsetting outcome of using insurance to pay for therapy is receiving a bill for hundreds of dollars from your therapist who you felt was "on your side". Your therapist was and is on your side. Unfortunately, it appears the insurance industry is not.
In conclusion, I want to express my astonishment that you have read this far. I could barely tolerate writing about this very boring topic, but out of consideration, I wrote to clarify some of the confusion. Generally, insurance coverage and paying for therapy is, at best, resting in the back of our minds, but I sincerely hope this explanation has helped - and will help, in the event the topic sneaks around to the forefront.
Full disclosure: I do not contract with insurance companies for ethical and personal reasons.