Access Premium Care: A Guide to Using Out-of-Network Benefits to Pay for Therapy
Insurance Jargon: 101
Navigating the world of insurance can be daunting, especially with confusing jargon. This section breaks down key terms to help you understand your coverage better.
In-Network Benefits
In-network benefits refer to services from healthcare providers that have contracts with your insurance, typically costing you less because your insurer sets the payment rates. When a therapist says they “take your insurance,” this means they are in-network with your provider. Most in-network therapists send your claims to the insurance company for you, but not everyone does.
Out-of-Network Benefits
Out-of-network (OON) benefits apply when you see providers who do not have a contract with your insurer, usually resulting in higher costs. OON benefits allow you to receive reimbursement for therapy services from mental health providers outside your insurance network. This means you can still access the care you need even if your therapist isn’t in-network. Most out-of-network therapists do not submit your claims to the insurance company, so you'll need to do it yourself by submitting a superbill to seek reimbursement.
Key Terms
Insurance Claim: A request from you to your insurance company for compensation for a covered healthcare service. If the claim is approved, the insurer pays you according to your policy terms.
Superbill: A detailed invoice provided by your therapist that includes information such as the type of service rendered, diagnosis code, and therapist's credentials. You'll submit this document to your insurance for reimbursement.
Deductible: The amount you pay for healthcare services before your insurance starts covering costs. For example, a $2,000 deductible means you will be responsible for paying for all therapy services out-of-pocket up to $2,000. Once you’ve paid $2,000 then your insurance will begin to reimburse you according to your copay or coinsurance.
Copay: A fixed amount you pay for a specific service, like a therapy session, at the time of the visit. This is the flat-rate amount that you pay after meeting your deductible, typically shared between you and your insurer. For example, a $15 copay means that after you’ve met your deductible, you will be responsible for paying $15 toward the session and your insurance will pay the rest.
Coinsurance: Instead of covering a flat rate as is the case of the copay, sometimes the plan will have what’s called coinsurance, which is a percentage that the plan will cover instead of a flat rate. This is the percentage of costs you pay after meeting your deductible, typically shared between you and your insurer.
Why Some Therapists May Not Accept Insurance
Many therapists choose not to accept insurance for various reasons, all aimed at providing the best possible care for their clients.
Flexibility in Treatment: Therapists who rely on insurance often have to follow strict guidelines and policies that may not align with individual client needs. Insurance may limit the number of sessions allowed or require specific diagnoses, restricting therapists' ability to tailor therapy effectively.
Financial Considerations: Insurance companies typically reimburse therapists at lower rates than their full fees. This often forces therapists to see more clients just to make ends meet, leading to burnout and reduced quality of care. By not accepting insurance, therapists can maintain a smaller, more personalized practice that fosters a comfortable therapeutic environment.
Confidentiality: Insurance companies often require therapists to share diagnosis information and treatment details, which can feel intrusive—especially for clients in high-performance jobs. Working outside the insurance system helps therapists protect their clients' privacy more effectively.
Administrative Burden: Complicated insurance processes lead to lengthy paperwork and reimbursement delays, creating additional strain that detracts from the essential client-therapist relationship.
While therapists genuinely want to offer accessible mental health services, they often confront complex insurance processes that can take time away from helping clients. This challenging balance highlights the pressing need for practical solutions that respect both the communities they serve and their own professional well-being.
Navigating Your Out-of-Network Benefits: Key Questions to Ask
Understanding how to utilize your out-of-network benefits can empower you to access the therapy you need. Here are some practical questions to consider as you navigate your coverage and the reimbursement process:
Does my insurance plan offer out-of-network benefits?
Check your benefits documents or contact your insurance provider to confirm whether out-of-network (sometimes called out-of-pocket) benefits are available.
What is my deductible and copay/co-insurance for out-of-network services?
Understand your deductible amount, as this will determine how much you need to pay before your insurance starts covering costs. For example, if your deductible is $1,000, your coinsurance is 50% and therapy costs $200/session, that means your insurance will require you to pay for the first 5 sessions ($200/session x 5 sessions = $1,000) out-of-pocket without being reimbursed by them. After that, they’ll begin reimbursing you $100 for every session ($200/session x 50% coinsurance=$100/session paid by them & $100/session paid by you).
Do I need a superbill to submit for reimbursement?
Confirm that your therapist can provide a superbill, which is necessary for you to file a claim with your insurance company.
What is the process for submitting a claim?
Ask your insurance company about the steps for submitting a claim for OON services, including any forms you need to fill out.
What documentation will I need?
Determine what information is required for your claim submission, such as session dates, diagnosis codes, and the type of therapy provided.
How long does the reimbursement process take?
Inquire about the typical timeframe for processing claims and receiving reimbursement from your insurance company.
By asking these questions and gathering the necessary information, you can navigate the complexities of using out-of-network benefits more effectively. Seeking support is a vital step toward emotional well-being, and understanding your options can help you access the care you need.
