Using Your Out of Network Insurance Options for Therapy: 11 Questions to Ask
You’re ready to reach out for some help because you’re tired of feeling stuck. You’re ready for change and the thought of navigating your insurance coverage is frustrating. Here at Relationships Redefined, we understand and want to help you.
We want to first recognize that you made it here. It may have taken all you can muster to finally seek out a therapist or counseling and you may feel exhausted, in pain, and confused about what to do next.
For people that want to use their out-of-network insurance benefits for counseling services, there is the tedious task of trying to figure out how it all works. We know this can be a confusing process, feeling like you’re going in circles, so we’ve written this post to provide you with an easy list of questions when calling your insurance company during this already difficult time. Navigating your insurance benefits can be confusing, but we hope that by the end of this article you will have more clarity and understanding. We also want to empower clients with tools and knowledge to make the best decisions for themselves.
At Relationships Redefined we are not contracted to work with any insurance panels, but are private pay. What this means is that we do not work directly with any insurance companies and require payment at the time of each appointment. We will not only provide a list of questions that will helpfully aid you in getting the information you are seeking for coverage but to provide an understanding of facts that your insurance company may not be informing you of.
We don’t contract with insurance panels for several reasons, and here are a few of them for you to consider:
Insurance companies limit and monitor the number of sessions a client is able to have.
Insurance companies can dictate how a therapist is able to work with a client.
Insurance companies don’t tell you the mental health diagnosis that is required on the superbill or statement they ask for stays in your medical file permanently. This means that something you may be struggling with today will be listed in your health file permanently. This can make it hard to be accepted for your choice of Life Insurance.We believe that our clients may have struggles they are dealing with, but that doesn’t mean they will struggle with these issues in the long term. We also believe that the issues you are struggling with today do not define you, it is separate from your own personal identity and you may be stuck here briefly until you find other alternatives to pursue.
Insurance companies are more in control of your mental health than you, the client, or we the counselors may be. Often, insurance companies allot a certain amount of sessions (often up to 6) and determine who you are able to see. Some insurance companies do not cover couples therapy sessions and limit you only to a list of a few providers in your area of their choosing. This means you don’t get to choose who you want as your therapist based on their expertise and specialty.
Finally, your confidentiality is also weakened. Insurance companies have access to all clinical notes which get passed through a number of different caseworkers, and records can be requested upon demand.
Those are only a few of the reasons, but here is what we can do to help you.
We will provide you with a monthly invoice and a diagnosis, also called a superbill. Only one person is able to be listed on the superbill, so if you are doing couples therapy, it’s best to call each partner’s insurance company to determine which one will provide the most coverage. It is recommended that you contact your insurance company prior to your first appointment to inquire about your coverage, limitations, copays, and deductibles. It is important also to note, that many people opt to not use their insurance to pay for therapy due to the release of information, including those diagnoses that remain permanently on your medical record that was mentioned above. Private pay and out-of-network services allow you the ability to see who you choose and to receive the best care and service that benefits you.
Do I have Mental Health insurance benefits?
Unfortunately, not all insurance coverage includes mental health benefits to use toward therapy or counseling services
What is my out-of-network deductible?
This will let you know how much money you need to spend out-of-network before your benefits will kick in. Deductibles vary by plan and can span from $500-$3000.
How much of my deductible has already been met?
This is how much more you need to spend in order to meet your out-of-network deductible. For example, if your out-of-network deductible is $1,000 and you’ve already spent $850, you will only need to spend $150 more before your out-of-network benefits kick in.
Are there any limitations to services (e.g., does my plan cover couples therapy)?
Some insurance plans do not yet cover couples therapy, but things are changing all the time so it’s important to ask and share this information with your therapist.
Are there a limited number of sessions permitted? Are there only certain types of diagnoses reimbursed, etc.?
A limited number of sessions may be initially allocated, and the insurance company will determine your needs on an as-needed basis. It’s also good to know if they only provide coverage for certain diagnoses. For example, they may not cover for desire discrepancy, but will only cover if either partner in couples therapy is struggling with sexual dysfunction such as erectile dysfunction.
Is a referral required from my primary care physician?
Some insurance companies may require a referral from your primary care physician to allow mental health services and benefits.
What is my co-insurance or reimbursement for an “out of network provider”?
How much will the insurance company send back to you for each session after you submit your superbill? This is the percentage amount that your insurance company will reimburse you for each visit (after your out-of-network deductible is met). Let’s say your therapy visits are $250 per session and you have a 60% coinsurance. This means your insurance company will reimburse you for 60% of the session fee, which is $150. After reimbursement, you will only come out of pocket $100 per visit.
How long will it take to receive the reimbursement?
This will help you to know how long it will take for the insurance companies to send you the coverage amount.
What is my policy period?
Similar to a “calendar year” policy which starts on January 1 and ends on December 31, a “policy year” is a 12-month time period specifically for your coverage start and end date, for example, August 1-July 31. It is important to determine your policy period when factoring in how much more time you have to meet your deductible.
How do I submit for reimbursement?
Typically, you will need to obtain a Superbill from your therapist and submit it to your insurance company. A Superbill is a document your therapist will provide at the end of the month that includes dates of service, a diagnosis code, a CPT code, and your therapist’s NPI and EIN numbers. Insurance companies have different ways to submit the Superbill: online, snail mail, or fax.
How long do I have to submit my Superbill?
Ok, so this is a bonus question. There is a time period after the “date of service” to submit the Superbill to your insurance company for reimbursement. Some may range from 90-180 days, and some insurance companies allow you to submit up to a year previous to the current date. Make sure you find out how much time you have to submit the Superbill after “the date of service” when calling your insurance company.
Note: Some insurance companies make special provisions for their clients who are already seeing a therapist. Occasionally, that therapist can be designated “in-network” for your case alone. This may be worth asking your insurance carrier about.
Relationships Redefined specializes in helping couples and individuals find fulfillment, connection, trust, and healthy communication in their relationships and offers online counseling focused in couples therapy & marriage counseling, individual therapy, premarital counseling, and intimacy and sex therapy in San Diego and all of California. Book a free 15-minute online consultation with us here! Make Intimacy Your Reality!