Using Insurance for Mental Health Care
So you've decided that you're in need of psychotherapy. Whether you are seeking this care for yourself individually, or whether you are in need of marriage or family therapy, most psychotherapy is covered by your health insurance policy. This process is not fundamentally different than how your health insurance policy works when you seek any other form of healthcare that is covered by the same policy. However, in the interest of transparency, here is a breakdown of what happens on the "using my insurance" side of things.
1) Health insurance covers healthcare services that are needed for a diagnosable health condition. The same is true for mental health. Mental health professionals must certify - with every single insurance claim - that the psychotherapy service they are providing meets "medical necessity"; that is, you must meet the criteria for a mental health condition. If you do not meet criteria for any mental health conditions, psychotherapy will not be covered by your policy. Your first appointment with a psychotherapist will be an intake assessment and will review elements of your psychosocial functioning as well as your behavioral health history to determine whether psychotherapy is medically necessary, and for what mental health condition.
2) Even though mental health professionals often have established out-of-pocket psychotherapy fees, if they choose to join your health insurance's provider network, they are required to accept the rate that your insurance company sets for the services that the therapist will be providing. Each of these services is represented by a CPT (Current Procedural Terminology) code. For psychotherapy services, these codes are generally determined by who is included in the psychotherapy session and by how long the session runs. Psychotherapists can usually not predict what your insurance company's rate will be, because these can differ down to the individual health insurance policy.
3) When psychotherapy is a covered service, depending on your specific health insurance policy, your psychotherapy coverage may or may not be subject to your policy's deductible, and you may or may not continue to be responsible for copays/coinsurances once your deductible is met. This, too, is not different from how appointments with any of your other health providers are covered. At one point in time, many health insurance policies maintained a deductible for mental health care that was separate from the deductible for your medical care, but this practice is not longer allowed in the United States.
4) If the mental health professional you are seeing is not in-network with your health insurance, they are not obligated to submit bills to your insurance company on your behalf if you have out-of-network coverage. Instead, they can issue you a document known as a "Superbill" that you submit to your insurance company. You are responsible for directly paying the mental health professional's fees, regardless of the amount of that fee you will be reimbursed by your insurance company. For instance: if your psychotherapist is out-of-network and charges $250 for a 45-minute individual therapy session (CPT code 90834), but your insurance will only reimburse you $110 for that session, you will still have to pay your therapist $250 but you will get a check from your insurance company for $110 once you have met any out-of-network deductible your policy might have.
5) If you have more than one health insurance policy, one of them must be designated as your primary policy. This primary policy will be the first one billed. If they do not cover the entire amount being billed, the claim will then be submitted to your secondary policy.
6) If your health insurance policy ends prior to the end of your psychotherapy treatment, insurance claims for any sessions held after the termination of your policy will be denied and your out-of-pocket cost will revert to the mental health professional's established out-of-pocket fee unless you have made other arrangements with your therapist.
If this sounds complicated, please know that this is the exact same process that all of your healthcare providers already follow. If you were going to see your primary care physician weekly for them to do treatments to remove a plantar wart from the bottom of your foot, they would diagnose the plantar wart at the first appointment, and then they would bill your insurance company for each subsequent visit during which assessment or treatment is provided, until the plantar wart is gone or until you stop attending appointments. If you decide that you really like going to your primary care provider and want to continue going to appointments after the plantar wart is gone, it would be unethical for them to continue to apply wart treatment to the sole of your foot and bill your health insurance for doing so, no matter how much you enjoy the treatments or have decided you need them. If the plantar wart returns or another one crops up, then the treatments (and submitting the bills to your health insurance) could resume.
For help with better understanding your health insurance policy, you have the following options:
A) Speak with a representative from your health insurance company. There is usually a phone number on the back of your insurance card that is for the patient/subscriber to call to ask questions.
B) For health insurance policies through your employer, you can usually get some general questions answered by speaking with a representative from your employer's human resources department.
C) Some healthcare providers employ administrative staff who can contact your health insurance company on your behalf to ask questions that are of a more technical nature, as long as they have your health insurance information and your permission to contact the insurance company.