How to Use Insurance with Out-of-Network Therapists

How to Use Insurance with Out-of-Network Therapists Starting therapy can be an important step toward better mental health, but finding the right therapist can be challenging—especially if the therapist you want to work with isn’t in your insurance company’s “network.” This can be frustrating when you want to use your insurance benefits to help cover therapy costs. In this article, we’ll explain what it means to be “out of network” and how you might still be able to use your insurance to pay for therapy. What’s the Difference Between In-Network and Out-of-Network Providers? In-Network Providers In-network therapists have agreements with insurance companies to provide services at a set rate. When you see an in-network therapist, you typically pay only your copay at the time of your appointment, and the therapist bills the insurance company for the remainder of the cost. Out-of-Network Providers Out-of-network therapists do not have agreements with insurance companies. This means that you will need to pay the full cost of the session upfront. However, you may still be able to get reimbursed for some of these costs by your insurance company. Can I Still Use My Insurance Benefits with an Out-of-Network Therapist? In many cases, yes, you can. While your insurance might not cover the cost upfront, it may reimburse you for a portion of the expenses if your plan includes out-of-network benefits. Here’s how to find out: 1. Check if Your Plan Covers Out-of-Network Costs Your insurance plan might state something like “covers 80% of out-of-network costs” or “after deductible is met, will cover 60% of out-of-network costs.” This means you may get reimbursed for a portion of what you pay. 2. Check Your Deductible A deductible is the amount you need to pay for healthcare services before your insurance starts reimbursing you. Deductibles can vary widely—some people have a $0 deductible, while others might have a much higher one. If you have a high deductible, you can submit your therapy receipts to count toward it. Once your deductible is met, you can start receiving reimbursements. What Does This Mean in Simple Terms? Navigating insurance can be confusing, but understanding your plan can help you determine which therapists you can work with and how much it will cost. Here are two common scenarios that might help clarify how this works: Example 1: No Deductible with Out-of-Network Benefits Let’s say you have an insurance plan with no deductible and it covers 80% of out-of-network costs. You see a therapist who charges $120 per session. You pay $120 at the time of your appointment, and your therapist gives you a receipt called a “superbill.” You then submit the superbill to your insurance company, and they reimburse you $96 (80% of $120). This means your out-of-pocket cost was only $24, which might be similar to or less than your usual copay. Example 2: High Deductible with Out-of-Network Benefits Now, consider a plan with a $5,000 deductible that covers 60% of out-of-network costs after the deductible is met. You’ve already spent $4,500 on medical care this year, so you have $500 left to meet your deductible. You see a therapist who charges $100 per session. After five sessions, you’ve met your deductible, and for the sixth session, your insurance company reimburses you $60 (60% of $100), leaving you with a $40 out-of-pocket cost. What If My Plan Doesn’t Cover Out-of-Network Therapists? If your plan doesn’t offer out-of-network reimbursement, it might seem like you’re limited to a short list of in-network providers. However, many people successfully appeal this by demonstrating that their insurance network doesn’t include therapists who meet their specific needs. For instance, you might be seeking trauma therapy using EMDR with a therapist who is LGBTQ+ affirming. If your insurer’s network doesn’t include therapists who specialize in both areas, you can explain this to your insurance company and request reimbursement for working with a specific out-of-network therapist who meets your needs. Many clients have had success taking this approach. Why Choose an Out-of-Network Therapist? There are several reasons why you might opt to see an out-of-network therapist, including: A higher level of specialization. Greater availability for new clients. Privacy concerns, as in-network therapists are required to share treatment notes with the insurer. Flexibility, since in-network therapists may need insurance approval for the number of sessions you receive. A strong preference for a particular therapist. How Do I Submit My Out-of-Network Costs to My Insurance Company? To get reimbursed for out-of-network therapy, you’ll need to submit a superbill—a detailed receipt your therapist provides. Before you submit the superbill or see an out-of-network therapist make sure your insurance provider does provide reimbursements or you may be required to pay fully out of pocket for these services. The superbill typically includes: The date and cost of your appointment. Your therapist’s name, license number, NPI number, and practice EIN (tax ID). A diagnosis code, if applicable. A CPT code that describes the service you received (e.g., individual therapy, couples therapy). Once you have the superbill, log into your insurance company’s website, find the “claims” section, and upload the superbill for reimbursement. You can track the claim to see if it’s applied to your deductible or if reimbursement has been sent. If dealing with insurance companies feels overwhelming, there are services available that can handle this process for you. These services will submit the superbill, follow up with the insurance company, and ensure you get reimbursed without the hassle.  Navigating out-of-network insurance benefits can seem daunting, but with the right information, you can make informed decisions about your care and take full advantage of your insurance benefits.