Understanding Your Insurance Benefits

pages

An important consideration in working with a therapist is determining how you will pay for sessions. As such, many therapy-seekers will want to explore utilizing their insurance benefits. While navigating insurance benefits can be challenging, understanding your plan will allow you to make an informed decision and save money in the long term.

Below is an explanation of how you can use your insurance benefits for therapy services.

In-Network Therapists

In-network therapists are contracted by insurance providers to see individuals at a pre-set rate. Depending on your plan, this means you will typically pay a copay of $20-65 per therapy session. In the more rare case that you have selected a high deductible health plan (HDHP), you will likely need to meet a set level of spending first (known as a deductible) before your insurance begins to cover your therapy costs.

Working with an in-network therapist is generally the most cost-effective way of receiving therapy. Therapists that are in-network will say that they “accept your insurance” or are “in-network” with Aetna, Cigna, or Blue Cross, Empire, etc. There are some downsides of looking for an in-network therapist. Many therapists in NYC choose not to contract with insurance providers and the ones that do are typically at capacity. In a survey of 272 NYC therapists in their network, Zencare found that only 20% were in-network with an insurance provider. If you want to work with an in-network therapist, you would restrict yourself to a small portion of available therapists.

When working with an in-network therapist, you pay the therapist the set copay at the time of the session.

Out-of-Network Therapists

Out-of-network therapists are not contracted with any insurance provider and set their own rates, also known as “self-pay” or “private pay” rates. In NYC, rates can range from $150-350+ per session. Factors such as degree, credentials, additional certifications, specialties, and experience all impact a therapist’s rate.

While going this route is typically more expensive, you will have access to many more therapists, in particular, specialists. Like all professionals, therapists are weighing financial viability when they consider whether to be in-network or out-of-network. Many NYC therapists choose not to contract with insurance providers as the reimbursement rates are disproportionately low in NYC, which is challenging given the higher cost of living.

While private pay rates are higher than copays, they are frequently partially reimbursable by your insurance plan by utilizing what is termed “out-of-network” benefits. If you have a PPO plan, you are likely to have out-of-network benefits. Reimbursement can range from 50-80% depending on your specific plan, which begins once you meet a minimum level of spending, known as a deductible.

When working with an out-of-network therapist, you pay the therapist the set rate each time you have a session. If you are able to receive reimbursement from your insurance provider, ask your therapist to provide you with a receipt, also known as a “superbill,” which you can then submit to your provider for reimbursement.

How to Determine Your Out-of-Network Benefits

Below is a step-by-step guide to determining if your plan offers out-of-network benefits and how much you would be reimbursed when seeing a therapist that is out-of-network.

Call the number on the back of your insurance card and ask the following questions:

  1. Does my plan include out-of-network benefits for outpatient behavioral and mental services?
  2. What is my annual deductible for out-of-network mental health benefits? How much of this deductible have I met?
  3. When does my deductible reset each year?
  4. Is there a limit on the number of sessions that my plan will cover annually?
  5. Are the following CPT codes for psychotherapy sessions covered: 90791, 90837, and 90834?
  6. Is there a limit on out-of-pocket expenses per year? How much? (This is the maximum amount you will pay in a plan year; once you exceed this amount, your insurance will pay 100% of all healthcare expenses. This amount resets each year.)
  7. What is the coinsurance percentage for mental health services that my plan will cover? (This is the percentage that your insurance will cover once you meet your deductible.)
  8. Do I need a referral or pre-authorization to receive services?
  9. What is the usual, customary, and reasonable fee (UCR) or the “allowed amount” for psychotherapy? They may tell you that this information is proprietary. This is not true. You are entitled to know what your plan sets as the allowed amount. Explain that you need this rate in order to know how much you can expect to be reimbursed after satisfying your deductible. For reference, the UCR rate in NYC for out-of-pocket psychotherapy is typically between $200 – $300.
  10. How do I submit invoices for reimbursement? (Most insurance companies allow for invoices to be submitted via their website.)

Additional Considerations

The following are additional learnings from my own experience navigating different insurance plans.

Average out-of-network deductibles: I have seen out-of-network deductibles range from $750 – $3,000. If you have a high deductible health plan, this amount can be as high as $10,000. Generally, your deductible is higher when you have a less expensive plan.

Making the most of your deductible: Keep in mind that deductibles reset every year. This means that each year, you will need to satisfy the deductible amount again before your insurance provider will begin reimbursing you for therapy. Most insurance plans reset the deductible amount on January 1. If you are considering therapy, the beginning of the year is an optimal time to start as you’ll get the most value out of your insurance reimbursement. Once you satisfy your deductible, you’ll qualify for reimbursement for the remainder of the year, until the deductible resets again the following year.

If your plan does not offer out-of-network benefits: Your options in this case are to:

  1. Work with an in-network therapist
  2. Pay out of pocket for therapy without going through insurance. You may find it worth the expense if you have found a therapist you connect with. For those in financial need, many therapists are amenable to offering a lower session fee, known as a “sliding scale” rate. Some therapists will request income/paystub documents in order to determine your rate, while others will have an allotted number of spots for sliding scale clients.
  3. Consider switching to a plan with out-of-network benefits. If your employer offers more than one plan, find out if the other option has out-of-network coverage. If so, you can switch plans during open enrollment in October or November.


Bridges co-founder Diana Liao (she/her) is a Manhattan-based licensed mental health counselor and psychotherapist who works with adults on life transitions and challenges related to identity, career, and relationships. She is passionate about working with diverse populations and is especially attuned to issues of belonging, marginalization, and other complexities that arise from navigating cultural differences. She is a native New Yorker and 2nd-generation Taiwanese American. Prior to practicing therapy, she worked in advertising and marketing.

SHARE THIS POST

Share on facebook
Share on twitter
Share on pinterest
Share on linkedin
Share on email
mood_bad
  • No comments yet.
  • Add a comment