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Understanding Insurance

What you need to know

Using insurance with a therapist is NOT the same as with a medical doctor.

Many who use insurance for their medical doctor elect to pay out of pocket for counseling. Likewise, a growing number of counselors and psychiatrists are choosing to avoid insurance entanglements as well. You owe it to yourself to learn why so many are making this choice.

 

the short version

A Balance Of Privacy VS Cost

Benefits

of using Insurance:

  • decreased out-of-pocket expense AFTER meeting deductible
  • before deductible is met, cost is equivalent to private-pay

Drawbacks

of using Insurance:

  • decreased privacy and confidentiality
  • potential consequences of receiving a mental health diagnosis
  • loss of control of your information and counseling autonomy

For the Long Version,

Keep reading below...

Benefits VS Drawbacks

of Using Insurance for Therapy

There are obvious financial benefits to involving your insurance company, but there are also some risks as well, especially if your provider is in-network. Let's look at the benefits and drawbacks.


Benefits:

  • The most obvious and largest benefit of using your insurance company, is a decreased out-of-pocket expense for you, once your deductible is met.
  • Some individuals wouldn’t otherwise be able to afford counseling, unless they use their insurance or go to a public health clinic or non-profit agency for lower cost treatment.

 

Drawbacks

  • There’s decreased privacy and confidentiality when an insurance company is involved because they require a mental health diagnosis to justify it being medically necessary for you to have therapy. This stays in your medical record permanently.
  • There’s also increased paperwork and a subsequent paper-trail that stays in your medical record and can be accessed for certain legal court hearings or when applying for things like life insurance.
  • It can sometimes be difficult to determine how many sessions you’ll actually be given per year, as they sometimes require continuing paperwork to justify that therapy is still needed and yet also is effective.
  • Sometimes there’s a care manager that’s involved and determining the course of treatment besides just what the client and therapist deem necessary.
  • In essence, I work for your insurance company, not for you... and am required to look out for their best interest over yours at times.

In VS Out

of network

Here are some basics about what it means to be In and Out of Network. Depending on your plan and deductible, counseling may end up costing the same either way.


In-Network Providers:

  • means that the insurance company has contracted with a group of therapists who have agreed to offer their services, usually at a discounted rate, so that clients can pay a co-pay (often between $20 – 40/session) and have the rest covered by their insurance company
  • there is often a deductible that you need to pay in full before your insurance company begins paying for treatment, often around $250 – 2,000 per contract year before they begin paying for therapy beyond your co-pay amount
  • insurance companies also have the right to audit client files for in-network providers so there’s less confidentiality/privacy and more paperwork to fill out and submit

Out of Network Providers:

  • there’s a lot more freedom with out-of-network providers because you can basically see any therapist that’s willing to provide you a monthly statement for reimbursement (called a Superbill)
  • means that the insurance company — usually a PPO like Blue Shield/Cross, Aetna, Cigna, United and not an HMO plan like Kaiser — will pay a certain percentage of the cost of a session for therapist outside of their in-network panel
  • what rate they’ll cover and for how many sessions depends on your insurance plan, but usually it’s somewhere between 30% – 80% of whatever full fee they determine is appropriate for the area (usually a fee that is less than the therapist’s normal rate)
  • In this case, usually the therapist will give you a monthly statement for you to submit directly to your insurance company for reimbursement. Therefore, you receive a check directly from the insurance company.

So What now?

How to proceed

The best thing you can do is ask your insurance company lots of questions, especially if they pay for out-of-network providers! Here are some helpful questions to use.

Noting the name of the insurance representative you speak with and the date/time can be helpful later on.


Questions to ask:

  1. Do they pay for out-of-network providers (i.e. HMO or PPO plan)?
  2. What is your deductible and has it been met?
  3. What percentage of the fee do they cover?
  4. Do they cover the therapist’s full fee or do they determine what a “usual, customary, reasonable fee” (UCR) is for the area your therapist is located in?
  5. How many sessions per year do they pay for? Do they give you these upfront or do they require you to incrementally ask for more until you reach the maximum amount per year?
  6. When does your insurance coverage for a year begin/end? When do your benefits renew?
  7. Do you need pre-authorization?
  8. What address do you send monthly invoices to?
  9. What is their turn-around time for sending you a reimbursement?

Watch a video

James Guay, LMFT put together this info in a video format.

 

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