Mental Health Insurance 411

We work with most health plans on what is called an “out of network benefit”.

Out-Of-Network – How it works.

Out-of-Network means that you would be responsible to pay the session fee at the time of each session and then apply for reimbursement from your insurance plan after submitting a receipt I provide (either a plain receipt or a special form called a ‘HCFA’/’CMS 1500’ form depending on your insurance carrier). Some plans do not have out-of-network coverage so it is important that you determine this before beginning if you are budgeting for reimbursement. The reimbursements vary from plan-to-plan even within the same insurance company (as do co-payments for “in-network” coverage) but they typically cover a percentage of the cost for each visit (anywhere from 50-80%). In some cases, there is a deductible – meaning you need to pay a certain amount before the insurance kicks in. See a schedule of my fees.

Each plan varies so you will need to call and ask the following questions:

  1. Do I have coverage for “out-of-network benefits for mental health”?
  2. Please explain my coverage. Do I have a deductible and what percentage do you reimburse for visits? Sometimes they ask for “procedure codes”. Here are typical ones:
    • 90791 – Psychiatric diagnostic interview (essentially our first session together)
    • 90837 – Individual Psychotherapy – 60 Minutes
    • 90847 – Couples Psychotherapy
  3. How long does it take to receive reimbursement(s) after submitting the receipt(s)/claim(s)?

In-Network – How it works.

Some providers are considered “in-network” providers. If you meet with an in-network provider you would be responsible for paying your copayment at the time of each session. This varies widely from plan to plan even within the same insurance company. The reason for this variation is that each employer makes a separate contract with an insurance company. So even if you and your friend have BCBS, one may have a $10 copay and another a $45 copay. The insurance company is responsible for the remaining cost. There can also be other restrictions such as a maximum benefit on a yearly or lifetime basis. Contact your insurance plan for details.

What If I Don’t Have Out Of Network Benefits?

If you do not have out of network benefits, you would need to decide whether to pay privately (out of pocket) or to take a referral to another therapist.

I hope this explains the process a little better. Insurance matters can be confusing and a hassle, let me know if you would like to discuss this over the phone or if I can be of help in getting you the information you need. If you are ready to set up an appointment, just let me know. If you prefer I make the call to your insurance company, please let me know.

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