Most Therapists Don’t Take Your Insurance
When it comes to mental healthcare, insurance works very differently than physical healthcare. It’s not like going to a doctor’s office, where they take almost any insurance. Most mental healthcare providers don’t take your insurance.
This is for a couple of reasons. Reimbursement rates are much lower than for physical healthcare. Also, guess what, it’s also really frustrating for mental healthcare providers to work with insurance.
Most mental healthcare providers are cash only. The market rate is between $120-200 a session. You may find a provider in-network, but be mentally prepared to have to pay out-of-pocket for therapy.
But, a lot of providers offer what is known as sliding scale - depending mainly on your income and ability to pay, providers will lower their rates.
Online, you’ll see providers say that they offer sliding scale. But, what you won’t see is how low they’re willing to go. We provide some resources for affordable therapy in the next section. However, outside these and similar resources, almost no therapist will go lower than $75 a session.
Honestly, it’s awful there isn’t transparency about pricing. Searching for an affordable therapist and negotiating will be stressful. But, you may have to, and you may find a provider who’s willing to work with you at a rate you can afford. I’ll talk more about negotiating and affordable options that later.
How health insurance works may seem complicated, especially if you’re younger, so I’m going to spend some time explaining how it works.
First, let’s say you see a provider in-network at their office, maybe in a plaza somewhere. They have a private practice or are part of a group practice. This is as opposed to a clinic or hospital. In insurance terms, this is known as an “office visit”.
For an office visit to an in-network therapist, you only pay a copay. To confirm, ask the therapist or clinic whether they put something like “office”, “doctor’s office” (even if the provider is a therapist and not a medical doctor), or “outpatient provider’s office” down for the “place of service” field on the reimbursement form they submit.
Online, you’ll see a lot of therapists say they “accept out-of-network insurance”. This is a very misleading phrase. You will have to pay these therapists in cash, upfront. They don’t ever work with your insurance company.
But, out-of-network insurance is a way to possibly get some money back from your insurance company. How much, if at all, varies wildly. But it’s possible you can get reimbursed around $30-75 per session by your insurance.
This is how it works:
Your therapist will provide you with what’s called a superbill, an invoice that contains information required by insurance companies.
Then, you fill out a form, either electronic or paper, and submit it along with the superbill to your insurance company. This is called submitting a reimbursement claim.
For the first several sessions, you won’t get reimbursed, but you still have to submit claims in order to eventually get reimbursed. More on this later.
You’ll get a check in the mail 3 months later. Yes, that’s a long time. How much you get back will vary each time, and your insurance company might not cover anything out of the blue.
Now, let’s say it’s not an office visit to an in-network therapist. There are four numbers to pay attention to: the deductible, coinsurance, maximum reimbursement rate for therapy, and out-of-pocket.
This applies to any out-of-network provider. It also works the same way for in-network, but if you’re going to a clinic or hospital. There are two sets of these numbers, for out-of-network and in-network, don’t confuse them when you’re asking your insurance company for details.
First, there’s what’s called a deductible. You have to spend a certain amount of money out-of-pocket before insurance kicks in. The deductible includes spending on all healthcare services, not just mental healthcare. The out-of-network deductible may include spending on in-network care, and vice-versa. The deductible may also include copays.
You also have to consider the maximum reimbursement rate for therapy. Different insurance companies call this different things, such as: the maximum reimbursable amount, maximum allowed amount, or the contract rate.
When calculating how much of your deductible has been met, or how much insurance will cover, they use this amount as the maximum for the service. The exact maximum reimbursement rate isn’t known ahead of time. You can access an estimate by logging into insurance website. It can vary on a day-to-day basis, so expect fluctuations in your exact reimbursement amounts.
Let’s use an example:
your deductible is $500.
the maximum reimbursement rate is $75 a session.
your therapist charges $150 a session.
If you see your therapist 3 times, you will have to pay them $150 * 3 = $450. You might think $450 has gone towards your deductible, and you only need to spend $50 more. This is not correct. Because the maximum reimbursement rate is $75, $75 * 3 = $225 has gone towards your deductible.
How much the therapist charged you doesn’t matter, only the maximum reimbursement rate. In this example, you would have to see your therapist 7 times and spend $1050 before insurance kicked in. 7 * $75 = $525, which is more than the deductible.
By the way, the way to tell your insurance company you’re meeting your deductible is by filing the reimbursement claim I described earlier. You have to file a claim for each session from day 1. It’s just that you won’t get any money back until your deductible has been met.
Now, let’s say you’ve met your deductible, and insurance has kicked in. For out-of-network care, insurance won’t cover the full amount. They cover a percentage, which is known as coinsurance. This coverage again extends only to the maximum reimbursement rate, not what you pay your therapist.
Let’s use the same example as before, and imagine you’ve met the deductible:
You pay your therapist $150.
The maximum reimbursement rate is $75.
The coinsurance is 50%.
Insurance covers $75 * 50% = $37.5. The end result is you pay $150 - $37.5 = $112.5 per session.
Finally, there’s what’s called the out-of-pocket. If, in a calendar year, you spend the out-of-pocket amount on your healthcare, you get a lot more coverage. Like the deductible, spending on all healthcare services, counts towards the out-of-pocket. Similarly, the out-of-network out-of-pocket may include spending on in-network care, and vice-versa. The out-of-pocket may also include copays.
For out-of-network therapy, if you’ve met the out-of-pocket, generally 100% of the maximum reimbursement rate is reimbursed.
Let’s use the same example, and say you’ve met the out-of-pocket:
You pay your therapist $150.
The maximum reimbursement rate is $75.
The coinsurance is now 100%.
You pay the therapist $150 a session, but get back $75 * 100% = $75 from insurance. The end result is you pay $150 - $75 = $75 a session.
HSAs And FSAs
You should have no problem using a health savings account (HSA) for out-of-network therapy. Just keep a copy of the therapist’s bill.
You can also use a flexible savings account (FSA). But, your claim might be denied and you might have to dispute this. Ask your HR what to do.
Checking Your Coverage
To get all the information needed, call your insurance company at the number on the back of your insurance member card.
Questions to ask your insurance company:
What is the name of my plan?
What is my copay for in-network office visits for outpatient mental health therapy?
What is my out-of-network deductible?
Do copays count towards the deductible?
Does in-network spending count towards the out-of-network deductible?
How much of my deductible have I met this year?
What is the out-of-network coinsurance for outpatient mental health therapy?
What is my out-of-network out-of-pocket?
Do copays count towards the out-of-pocket?
Does in-network spending count towards the out-of-network out-of-pocket?
How can I find the maximum reimbursement rate?
Do I need a referral for in-network or out-of-network outpatient mental health therapy?
How do I submit a claim?
(About a specific therapist) is a therapist in-network with me?
- Most therapists don’t take your insurance.
- Therapy costs $120-200 a session.
- A lot of therapists offer sliding scale - lower rates for people who can’t afford it.
- You can file reimbursement claims with your insurance company to get anywhere from $30-75 back per session, even if the therapist doesn’t take your insurance. This is called out-of-network insurance.
- Deductible - the amount of money you have to spend out-of-pocket before out-of-network insurance kicks in.
- Maximum reimbursement rate - the maximum amount per session that: counts towards your deductible and out-of-pocket, or that you can get reimbursed for.
- Coinsurance - the percentage of the cost per session, up to the maximum reimbursement rate, your insurance will reimburse you for.
- Out-of-pocket - the amount of money you have to spend after which your insurance covers 100% of out-of-network costs, up to the maximum reimbursement rate.
- You can use HSAs and FSAs to pay for out-of-network therapy.
- Call your insurance provider to get all the information you need.