When a provider is in-network with your insurance company, you generally only pay a copay or co-insurance. The insurance company directly pays your provider the remainder of the fee, to which the provider and insurer agreed.
Some key words:
A copay is a set fee you pay per session - usually $20-$50.
Coinsurance means that you pay a percentage of the cost - for example, %20.
A deductible is an amount which much be paid out-of-pocket before some or all insurance benefits kick in. Many high deductible insurance plans, for example, may require an individual to spend several thousand dollars before coinsurance begins.
When a provider does not take your insurance, you may still be able to obtain some reimbursement, provided your insurer offers out-of-network (OON) benefits.
To determine the details of your out-of-network reimbursement:
Call the member services number on the back of your insurance card and ask for the benefits department, or something to that effect.
Ask whether your policy covers OON psychotherapy services provided by a licensed clinical social worker.
Ask whether your policy covers the following procedure codes: 90834 and 90837. These codes represent 45- and 60-minute individual therapy sessions, respectively.
Ask what the "allowed amount" is for both codes.
Ask whether your reimbursement is based on the fee you paid or the allowed amount.
Ask what percentage (of either the fee paid or the allowed amount) is reimbursed.
Ask whether any mental health diagnoses are not covered by your insurance.
Ask whether there is a limit to how many sessions are covered per year.
Ask what your OON deductible is and how much of it you may have already met.
Many insurance companies will reimburse you a percentage of the total fee paid. For example, they may reimburse you for 80% of a $120 therapy session. Others will substitute the fee you actually paid for their "allowed amount" and then reimburse a percentage of that number. For example, while you may have paid $120 per session, if the allowed amount is only $90, and your insurer will reimburse you 60% of that, then your reimbursement would be $54 for each session. Your out-of-pocket expense would be $66 per session.
Some providers will provide you with a bill which you must submit to your insurance company yourself for OON reimbursement. Others, including me, will file the claims on your behalf, directly with your insurer.
Regarding question #9, the size of your OON deductible can have a significant impact on how much, if any, reimbursement you will obtain. Many insurers have a separate deductible for in-network vs. OON expenses. If your OON deductible, for example, is $6,000, it is unlikely you would ever spend enough on therapy in a given year to meet this figure and have your OON benefits kick in. In this scenario, it would require 50 sessions at $120 to reach this deductible. Your OON benefits would only cover the final two sessions of the year, assuming you are attending weekly.
FSAs and HSAs can be ways to reduce the expense of therapy, by using pre-tax income.
Your accountant or tax preparer may have advice on deducting medical expenses.
You may also be able to choose plans that have more generous OON benefits, even if the premiums are higher.