Insurance Coverage for Therapy: Discovering Your Benefits and Cutting Therapy Costs
Navigating mental health therapy coverage can be a complex task, but this guide aims to simplify the process by providing a clear overview of the key components involved.
The Basics
The Affordable Care Act and the Mental Health Parity and Addition Equity Act ensure that insurance companies treat mental healthcare the same way they would any other medical specialty. This means that most insurance plans cover individual therapy, psychiatric services, and some couples and family therapy options when treatment is medically necessary.
In-Network vs. Out-of-Network
In-network providers have contracts with your insurance company, resulting in lower copays and coinsurance. Out-of-network therapy usually costs more, but with PPO and POS plans, some partial coverage may apply. It's important to note that out-of-network reimbursements are limited to an "allowed amount," so if a therapist charges more, you pay the difference.
Deductibles, Copays, and Coinsurance
Most plans require you to meet an annual deductible before coverage starts. This ranges from hundreds to thousands of dollars depending on the plan. After the deductible, many plans apply a fixed copay per therapy session (often lower for in-network providers) or coinsurance, where you pay a percentage of the session cost.
Session Limits and Referral Requirements
Insurance policies may cap the number of covered therapy sessions per year, and exceeding these limits means paying out-of-pocket. HMO plans require choosing a primary care provider and obtaining referrals before seeing a mental health specialist, while PPO plans allow more flexibility with no referrals needed.
Other Considerations
To claim out-of-network reimbursement, you usually need a detailed receipt ("Superbill") from your therapist. Therapists in-network must accept the insurer’s contracted rate and cannot charge you more than the copay, but out-of-network therapists set their own fees.
Summary Table
| Feature | HMO | PPO | EPO | Medicare (Part B) | |-----------------------|-------------------------|--------------------------|--------------------------|-----------------------------------| | Network | In-network only | In- and out-of-network | In-network only | Any approved provider | | Referral needed | Yes (PCP referral) | No | Usually yes | No | | Out-of-network coverage | None | Partial (after deductible) | None | Covered if provider is Medicare approved | | Deductible | Usually yes | Yes | Usually yes | Yes ($257 in example) | | Copay/coinsurance | Copay, fixed per session| Copay or coinsurance | Copay | 20% coinsurance after deductible | | Session limits | Often yes | Often yes | Often yes | Depends on setting | | Payment to provider | Direct | Direct or reimbursement | Direct | Direct |
Additional Resources
It's essential to call your insurance company to ask about specifics, such as whether mental health is covered, what your out-of-pocket costs are, whether your deductible applies to therapy, and if a referral is required.
Insurance typically covers grief counseling as it falls under the Mental Health Parity and Addiction Equity Act. Health Spending Accounts (HSA) and Flexible Spending Accounts (FSA) let you set aside pre-tax money for healthcare costs, making out-of-pocket therapy costs less expensive.
Online therapy is typically covered by insurance as long as services are provided by a licensed mental health professional. Some insurance plans, such as HMOs and government-funded plans like Tricare or the Community Care Network, do require a referral from the primary care provider.
Employee assistance programs (EAP) might offer free mental health support, separate from your regular insurance, and typically require a referral and include a set number of free therapy sessions with a licensed provider.
The number of therapy sessions covered by insurance varies significantly by plan, with some plans capping annual sessions at the lower end (20 sessions), while others allow up to 60 sessions or more. Psychiatric services like medication management and periodic check-ins with the prescribing provider are usually included in mental health benefits.
Insurance typically covers therapy when it is deemed medically necessary, but a diagnosis may be required during treatment. Starting a conversation with a potential therapy provider by asking if they are in-network with your insurance plan and if they can verify your coverage is a good practice.
- Given the complexity of navigating mental health therapy coverage, it's worth considering that some insurance policies might cover online therapy as long as it's provided by a licensed mental health professional, much like traditional therapy sessions.
- The Mental Health Parity and Addition Equity Act ensures that insurance companies treat mental health services, such as grief counseling, similarly to physical health services, thus making these counseling sessions potentially eligible for coverage under one's insurance plan.
