A Simple Guide to Navigating Insurance
Insurance can be a wonderful resource for reducing the financial barrier to accessing therapy. But it can also be an exhausting process to navigate. I value transparency, and my goal with this blog is to provide you with a simple guide to demystify your insurance so that you are more informed about what your insurance actually covers, and what it does not. If you are curious about my private practice, I am “in-network” with Cigna, Aetna, and Optum/United plans, and accept Optum EAP. I am credentialled to accept these plans through the Alma Provider Network. I also accept Self-Pay Clients, with options for Super-Billing and FSA/HSA card use. If you are interested in learning more about my services and rates feel free to follow the links provided.
Before we get started with clarifying your specific plan coverage for therapy, I want to remind you that EVERY insurance plan is different. Even if you start your therapy journey with a therapist that accepts your insurance plan, that does not guarantee that your therapy is covered by insurance. Most therapists, including myself, will support you in investigating what your therapy coverage actually is, but it is ultimately your responsibility as a client to investigate and know what your coverage is before your first session of care because you are the one that is responsible for paying for therapy. I think it’s especially useful to investigate your coverage before searching for prospective therapists. It’s better to know what your benefits are before the very first session than to be surprised by a very high unexpected bill after your first (or many sessions).
“Insurance Speak”
Insurance companies use a lot of complicated terms to explain what your coverage is. Learning to speak the language of insurance is essential in understanding what your benefits actually are, so here’s a quick “cheat sheet” to help with your understanding:
A co-payment is a flat fee that you pay for each session. It is usually given in a dollar amount when you call your insurance company. If you have a co-payment, this is the amount you pay out of pocket and insurance covers the rest.
A deductible is the total amount of money that you (and/or your family) will need to pay out of pocket before your insurance benefits can be used. If you have not met your deductible, you will have to pay out of pocket for every therapy session at your therapist’s contracted rate until you reach the total amount outlined by your insurance plan.
Co-Insurance is typically a percentage of what you will pay for each therapy session once you reach your deductible. For example, if you have a 0% co-insurance, this means that you’ll pay 0 dollars for each therapy session once you reach your deductible, and your insurance will cover the full contracted rate for each therapist.
An Out-of-Pocket Maximum is the total amount that you need to spend before your insurance plan starts paying 100%.
A contracted rate is the rate that your therapist has agreed to be paid for each session of therapy as an In-Network Provider.
An In-Network therapist is a provider who is credentialled to bill your insurance company and accepts your insurance plan.
CPT Codes are the codes that therapists use to file claims for the services you receive for therapy. CPT codes 90837 (60-minute sessions) and CPT Code 90834 (45-minute sessions) are fairly common for most individual therapists.
Calling your Insurance
Your first step in using your insurance benefits to access therapy is to get clear on what coverage your insurance plan actually provides. I recommend starting this process by calling the “Member Benefits” or “Member Services” number on the back of your medical insurance card. If you can, try to call at a time when you can dedicate at least an hour to your phone call… this process is smoother if you can speak to a live person about your coverage, as opposed to a robot. If you’re feeling impatient you can always try saying “Speak to a live person” or hitting 0 on your keypad. Make sure to take notes during this call. If you’d like to have a note catcher to guide your questions you can access one here.
Once you are connected with a live person, you’ll need to ask “What is my coverage for outpatient mental health benefits?”. Some other essential questions to ask are:
When do my benefits start and renew?
Are CPT codes 90837 and 90834 covered? Both for telehealth and in-person?
Is telehealth covered in addition to in-person?
How many sessions am I covered for? Is my coverage unlimited?
What is my copayment or coinsurance for telehealth and office sessions?
Do I have a deductible that I need to meet before accessing my outpatient mental health benefits? Is this deductible waived when I see an “in-network provider?”
How much of my deductible have I met so far this year?
Do I have an out-of-pocket maximum?
Finding an In-Network Therapist
Once you’ve investigated your coverage, and feel that you have a strong understanding of what your benefits actually are for therapy, it’s time to find a therapist that is “In-Network”. You can find an In-Network therapist through a variety of paths. This is not an exhaustive list, but just some ideas to get you started. Remember, the prospective therapists you contact might be able to support you in exploring and verifying your insurance coverage, but it is ultimately your responsibility to understand your coverage before the first session.
Path One: Use PsychologyToday or TherapyDen to find a therapist near you. Use the provided filters in the search bar to filter for your insurance provider to find a therapist that is “In-Network”. When you schedule your phone consultation or email prospective therapists, make sure to ask “Are you an in-network provider with my insurance?” and “Can you help me understand what my out-of-pocket costs might be for a session with you?”.
Path Two: Use a Provider Network like Alma, SonderMind, or Headway. Provided that you are VERY clear on your insurance coverage for therapy, the provider networks can be the fastest and easiest way to find an In-Network Provider. Most of the providers within these networks are credentialed to accept major insurance companies. You’ll typically need to answer just a few questions to search for a therapist that’s right for you, currently accepting new clients, and takes your insurance. The turnaround from when you first make contact with a prospective therapist and your first therapy session can be fairly quick too. When you find a therapist that is a good fit for you, make sure to clarify what the estimated out-of-pocket costs might be before scheduling your first session. This can be done by talking with your therapist about their “contracted rate” and/or accessing client resources through the Provider Network of your choice.
Path Three: You can utilize your insurance company’s website to find an In-Network Provider. Every insurance company’s website is different, but most major providers have a database to search for behavioral health care providers and therapists, just like you would for an In-Network Doctor.
Path Four: Ask your Doctor for a referral. Depending on your insurance plan you may need to ask your Doctor for a referral to a therapist in order to access your In-Network benefits. This is especially true for folks that have a POS (Point of Service Plan).
Have a “High Deductible” Plan?
So after your insurance call, you learn that you have a “high deductible plan”, meaning you’ll have to meet an individual deductible of $1,400+ or a family deductible of $2,800+ before your insurance benefits kick in. This means that you’ll have to pay for every session of therapy completely out of pocket until the deductible listed is met. Sounds daunting right? The good news is there are still a few options you can investigate to support with accessing therapy:
Option 1: Do you have an HSA card? Depending on the In-Network Therapist, you may be able to use your HSA card to cover the cost of therapy until you reach your deductible.
Option 2: Does your work have EAP (Employee Assitance Benefits)? If so, you may be able to access a limited number of free therapy sessions for you, or your family member at no cost to you. I’ll share more on accessing EAP in a later blog post.
Option 3: Depending on your In-Network deductible, and how high it is, it may be more cost-effective to look for a therapist that is out-of-network with your insurance or self-pay only. When using your in-network benefits with an unmet high deductible plan, the bill that you will pay for each session of therapy may be a lot higher than the self-pay rate for some therapists. If you choose this route, you might want to explore your Out-of-Network benefits with your insurance carrier, which will be explored in a future blog post.
Concluding Thoughts
Insurance literacy is an undervalued skill and essential for accessing therapy. My hope is that this post supports you in clarifying what your insurance plan will cover when you chose to access therapy through your benefits, without the added stress of unexpected bills. Finding the right therapist shouldn’t be this hard, and I wish I had the power to change the whole system of accessing mental health care. Since I’m unable to single-handily change a complicated and inequitable system, I hope this post provides you with the necessary resources to make empowered decisions about how to access therapy.
Resources used to develop this post and note catcher:Griswold, B. (2022, October). Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – And Whether You Should (Ninth Edition). San Jose; Barbara Griswold, LMFT. 