Understanding Your Insurance Coverage for Therapy: A Guide to Navigating Benefits, Copays, and Superbill Options
You’ve done your research. You’ve found the perfect match for a therapist. You may now be wondering: How will I pay for this valuable service? Have no fear, because we are here to help break down your common insurance questions.
Am I In-Network or Out of Network?
This is the best place to start. Before beginning services, ask your therapist if they are in or out of network with your insurance plan. If they are in network, that means they have a contract with your insurance company to provide services for its members. If they are out of network, they do not have a contract with your insurance plan. Using an out of network provider usually means a higher out-of-pocket cost of service for you, which is why many work hard to find a provider that is in network with their insurance plan.
What is a Superbill?
If your therapist is out of network with your coverage, you may still have options. Some insurance plans have out of network benefits, and some don’t. This is unique to each plan. The best thing to do is call the member services phone number on the back of your insurance card and ask. If you do have out of network benefits, your insurance company will ask you to provide a Superbill for the services you received with your therapist. Don’t worry-a Superbill is not an actual bill. It is a document that will have all the information your insurance company needs to process your out of network claim. Your therapist’s billing office can provide this document for you.
My Plan is In-Network. Do I have a Copay, Deductible, or Coinsurance?
Many practices will offer to check your benefits for therapy services as a courtesy, however you can also call your member services line and ask to be sure. You will want to ask what your benefits are for mental health outpatient care in an office setting. Here are the ways your sessions may be covered:
Copay: A copay is an assigned, fixed amount you will pay per visit with your therapist. The amount varies per plan. For example, if you have a $25 copay, you will be responsible for paying $25 for each therapy session. Your insurance will cover the rest of the cost.
Deductible: Many insurance plans want you to pay down your deductible before they will share the cost with you. Deductible amounts vary by plan. When therapists contract with insurance companies, they have a set amount insurance will pay for each type of service the therapist offers (called a contracted rate.) You will pay that contracted rate for the service you are receiving until your deductible is met. Once it is met, insurance may share the cost with you. This is called a coinsurance. Coinsurances are typically paid until your out-of-pocket maximum is met.
Coinsurance: Once you have met your deductible, your insurance plan may start sharing the cost with you. Typically, your coinsurance is a percentage of the contracted rate, and your insurance plan will pay the rest. If you have a 20% coinsurance, that means that you will pay 20% of the contracted rate for your service, and your insurance plan will pay the other 80%. This will continue until you out of pocket maximum is met. Your out-of-pocket maximum is the maximum amount of money your insurance requires you to pay out before they cover your services 100%. Your out-of-pocket maximum is usually larger than your deductible, and varies by plan.
Remember, the benefits check your therapist’s billing team gives you is an estimate. Sometimes, insurance receives the claim and it may process differently than predicted. This is why it is very important to have a good understanding of what your insurance benefits are. Insurance companies make mistakes too, and when you know your benefits it is much easier to tell when something doesn’t look right.
In Conclusion
Insurance coverage can sometimes feel a little daunting when you start dipping your toes in, but the key is knowing to ask the right questions. Your member services line on the back of your insurance card is the best place to start. Many therapists work in an office with a billing department. Check with your provider to see if there is someone in their office you can speak to with your insurance questions. With some preparation, accessing mental health care with insurance can be manageable. We are here to help!