Finding a therapist who feels like the right fit can be challenging. It can become even more confusing when you learn that the therapist you want to see is not in network with your insurance plan.
The good news is that some insurance plans include out-of-network benefits that may reimburse you for a portion of the cost of therapy. Understanding how these benefits work can help you make a more informed decision about your care.
What Is the Difference Between In-Network and Out-of-Network Therapy?
An in-network therapist has a contract with your insurance company and has agreed to accept its negotiated rates. You typically pay a copay, coinsurance, or deductible amount, and the therapist bills the insurance company directly.
An out-of-network therapist does not have a contract with your insurance company. You pay the therapist’s full fee at the time of service. If your plan includes out-of-network mental health benefits, you may then submit documentation to your insurance company and receive partial reimbursement.
Not every insurance plan includes out-of-network coverage, so it is important to confirm your specific benefits before beginning therapy.
How Do I Find Out Whether I Have Out-of-Network Benefits?
Call the member-services number on the back of your insurance card and ask specifically about your out-of-network outpatient mental health benefits.
Questions you may want to ask include:
- Does my plan cover out-of-network outpatient mental health services?
- Do I have a separate out-of-network deductible?
- How much of that deductible have I already met?
- What percentage will the plan reimburse after I meet the deductible?
- What is the plan’s “allowed amount” for the service?
- Do I need a referral or prior authorization?
- Are telehealth sessions covered?
- How do I submit a superbill or reimbursement claim?
- Is there a deadline for submitting claims?
If you are seeking couples therapy, ask whether your plan covers therapy involving a partner and under what circumstances. Insurance generally requires treatment to be medically necessary and connected to a mental health diagnosis. It does not typically cover couples therapy.
What Is a Superbill?
A superbill is a detailed receipt that may include information such as:
- The client’s name and identifying information
- The therapist’s name, license, and professional identification number
- The date and type of service provided
- The amount paid
- A diagnosis code and service code, when applicable
You submit the superbill to your insurance company according to its reimbursement procedures.
A superbill does not guarantee reimbursement. The amount you receive depends on your particular plan, deductible, allowed amount, and coverage requirements.
What Does “Reimbursed at 60%” Actually Mean?
This is one of the most confusing parts of out-of-network coverage.
If your insurance company says it reimburses 60%, that does not always mean it will reimburse 60% of the therapist’s full fee. It may reimburse 60% of what the insurance company considers its allowed amount…and only after you have met your out-of-network deductible.
For example, imagine that a therapy session costs $200, but the insurance company’s allowed amount is $140. If your deductible has already been met and the company reimburses 60% of the allowed amount, your reimbursement may be $84 rather than $120.
Because plans vary considerably, ask the representative to explain your expected reimbursement using the therapist’s actual fee and the relevant service code.
Why Do Some Therapists Choose Not to Join Insurance Networks?
Therapists make this decision for many reasons. Remaining out of network may allow a therapist greater flexibility regarding session length, frequency, treatment approach, and the type of work offered.
Insurance companies generally require a mental health diagnosis and may place limits on what they consider medically necessary. Private-pay and out-of-network therapy can sometimes provide more flexibility for people seeking specialized services, extended sessions, couples therapy, or intensive therapy.
You deserve to understand the financial side of therapy before committing to care. A short call to your insurance company can help you determine whether out-of-network benefits make working with the right therapist more accessible.
If you are looking for a therapist in New Orleans or throughout Louisiana, contact Modern Therapy & Wellness to learn more about our clinicians and current availability. When contacting us, you are welcome to ask about session fees, available clinicians, or reduced fee openings. We do currently have some reduced fee openings.
Modern Therapy & Wellness is a New Orleans therapy practice offering individual therapy, couples therapy, and relationship-focused services. Email us to set up a free consultation: info@moderntherapyandwellness.com