Self-Pay vs Insurance
Ways to Pay for Counseling
Self-Pay
You pay for your counseling sessions directly, out-of-pocket, rather than using insurance. Cost for sessions vary based on what type of session you are requesting, but services can be more tailored to your needs as determined between you and your counselor. Benefits: no mental health diagnosis required, higher level of privacy, control over types of sessions and length of therapy, choice of therapists. Ask our office about sliding scale, where we adjust our fees based on household size and proof of income to make counseling affordable without the use of insurance.
Insurance
Third party insurance pays for your counseling sessions according to the policy agreement you signed up for based on medical necessity. A mental health diagnosis is required and insurance may request to view your records. One type of plan may be a copay or coinsurance plan where you pay a certain dollar amount or percentage for each session based on the service type. Another may be a deductible plan where you must pay the allowed amount until your deductible is met before insurance will pay for a portion of the sessions. Benefits: affordable costs, use benefits you already pay for with your premium, service standards regulated and providers vetted by insurance.
What Does My Insurance Cover?
Call the toll-free number often found on the back of your insurance card for questions related to mental health benefits. If you don’t have one, contact the representative when you enrolled in your healthcare coverage.
Ask the following questions to learn more about what your mental health benefits are, if any.
- What are my benefits for behavioral health? There is a difference between inpatient (hospital setting), intensive outpatient (partial hospitalization programs or intensive outpatient programs), and outpatient in-office setting (private practice counseling like Redefine).
- What is my deductible and how much has been met?
- What is my out-of-pocket maximum and how much has been met?
- How many sessions per calendar year does my plan cover? What date does it renew?
- Ask about specific types of sessions they cover: For Couples: Do you cover the following couples counseling? (CPT Code 90847) Unmarried Couples: Does the couple have to be married? For Children and Teens: Do you cover family therapy with patient present (CPT Code 90847) and family therapy without patient present (CPT Code 90846, often used for parent-only meetings)?
- Does my plan have out-of-network benefits? How much does my plan cover for an out-of-network provider after my deductible has been met?
- Is approval required from my primary care physician?
- Are virtual outpatient mental health visits (or teletherapy) covered by my plan?
- If you have more than one insurance plan: Is this policy considered my primary or secondary insurance?
What about Out-of-Network Benefits?
Some insurance policies offer “Out-of-Network” benefits. This means a you can still see a healthcare provider who is not contracted with a particular health insurance company. Every plan is different so you will need to call your insurance to find out details. Often, patients will pay the full cost of a therapy session, then submit forms required by their insurance provider along with a Superbill they receive from the counselor that has the mental health diagnosis given. The patient then gets directly reimbursed by insurance for a portion of their expenses. This reimbursement process may take several weeks up to months.
Not sure if you want to go this route for Out-of-Network? Ask your insurance provider is they will allow a Single-Case Insurance Agreement. This is a contract between an insurance company and an out-of-network provider to allow a limited number of sessions to be covered by their In-Network benefits.
When seeking a single case agreement with your insurance provider, the insurance company will want additional information that our office can provide. This may include what you are wanting to be treated for, why the provider you’re wanting to see is unique compared to other providers in your area that are In-Network, what “CPT codes” will be used for billing services, etc. When speaking with your insurance provider, record and document every phone call including names, dates, times, what was discussed, a reference number, and how you were advised. You may also consider putting requests in writing such as an email.