Using Your Insurance

I am an Out-Of-Network mental health/behavioral health provider. What does that mean?

Every insurance plan will vary with coverage, but I wanted to provide some general information about insurance plans' options. You will need to refer to your insurance provider to learn more about your specific coverage. You can often find information on the plan's website, or you can call the customer service number on the back of your insurance card.

Generally, insurance plans have two types of coverage: in-network and out-of-network.  In-network coverage means that you can see a therapist who has a contract with your insurance company.  Some insurance plans have out-of-network benefits.  With out-of-network benefits, you can get reimbursed for seeing a therapist that is not contracted with your insurance.

Using In-Network Coverage

Using In-Network benefits might be a less expensive option, but here are things to keep in mind if you want to use your in-network coverage:

  • You will often need to pay a copay at every session, often varying from somewhere between $5-45
  • If you have a plan with a deductible, your insurance might not pay for services (even in-network services) until the deductible is fully or partially met.
  • Your insurance company will determine if your therapy will be covered and how many sessions it will a lot based on the diagnosis the therapist submits and sometimes even the therapist notes if the therapist is audited. Some individuals do not meet any criteria for a diagnosis and would most likely not be covered by insurance.
  • Some people do not want to have a mental health diagnosis in their health records or have an insurance company determine the care that they are given.
  • You will have a limited number of therapist that will be "in-network" accepting your insurance and has openings in your area, as the insurance company limits this number

Using Out-Of-Network coverage 

Using Out-Network benefits will give you more options when looking for a therapist, but here are things to keep in mind:

  • You will pay for the therapy upfront, and then I will provide you with a receipt of service that you will need to submit to your insurance company for reimbursement
  • Insurance companies generally reimburse between 40-80% of the treatment cost.
  • The insurance company will need the therapist to submit a diagnosis, and they will not always cover treatment based on the diagnosis.
  •  You will have more options for therapists than in-network therapists.
  • You might have a deductible that you must pay in full or partially before getting a reimbursement. The deductible also might be different than your in-network deductible.

 

 

Your plan might have other options for care, as every plan varies. I recommended calling the customer services number on the back of your insurance card to learn more about your coverage.

What questions should I ask my insurance company about Out-Of-Network coverage?

Before calling your insurance company's customer services, have your Insurance Card ready with your ID#, Group#, and other plan information. You will also need to know the primary subscriber's information (which might be you), including the subscriber's birthday and employer.

Questions you might ask:

  1. Let them know you want to start outpatient mental health benefits/behavioral health services in a professional office or via telehealth.  Then you can ask, does my plan cover out-of-network providers for this service?
  2.  If so, what is the coverage (either the percentage or the amount they will pay, or you will pay)?
  3. Does my plan have coinsurance?
  4. If you are interested in using telehealth services, will this be temporary for the pandemic period, or will it continue? 
  5. Do I have a deductible, and do I have a separate deductible for in-network and out-of-network?
  6. My therapist charges $185 for a 45 min therapy session (Service Code/CPT 90834).  Is this code covered by this insurance? How much will be covered per session? Is there a cap amount for reimbursement?
  7. Is there a limit to the number of sessions per year?
  8. Is there an Out-of-Pocket Maximum before insurance will cover all of the cost?
  9. Is my coverage active? When do benefits get renewed (when the deductible renews)?
  10. My therapist said they would provide me with a superbill (essentially an invoice) that includes her License information, address, NPI, EIN, billing code, diagnosis, and fees. How do I submit these superbills to my insurance plan for reimbursement? Is there an additional form I need to fill out?

If you would like to find an In-Network provider?

Unfortunately, I am not an in-network provider with any insurance companies. If you want to find a therapist that is in-network with your insurance, I recommend visiting your insurance website or calling the insurance customer services number. Both should be listed on your insurance card.