IN-DEPTH GUIDE TO OUT-OF-NETWORK BENEFITS

When looking for a therapist, you have the option to choose between in-network and out-of-network providers. In-network therapists work directly with your health insurance company and are typically more affordable than out-of-network therapists

In big cities, therapists who take insurance tend to be booked to full capacity and have long wait times for appointments. 

If you decide to go the out-of-network route, you will have to pay the full price for the session upfront. Depending on your plan, your insurance company may help reimburse a portion of the cost by mailing you a check. 

Use the following steps to learn how to check your out-of-network benefits. Though this process can be frustrating, it may help save you money in the long run. Having the details upfront can help you prevent any unexpected costs. 

At Flow, you can request a monthly superbill to submit for your out-of-network claim. 

Note: If you live outside of California, you will not be eligible for insurance reimbursement. 

Ok, you're ready to call your insurance company.  Let's dive in!

Photo by Katie Miller

A little explanation about deductibles and co-insurance 

  • Deductible: This is the amount of money you have to pay before you are eligible for reimbursement. 

  • Co-insurance: This is the percentage of the fee that you're responsible for paying once your deductible is met. 

Let's say your deductible is $1,500, your co-insurance is 50% and sessions cost $175.

 

That means you'll have to pay $1,500 full-fee out of pocket, after which you'll have "met your deductible." Then you'll be responsible for paying 50%, or $87.50. You'll pay the therapist the full $175 upfront. Your insurance will send you a check for $87.50 after the session, once you've met your deductible and submitted a claim. 

I wish we could stop there!

Here's where it gets tricky ~ In my experience, many insurance companies determine an "allowed amount," which caps the session fee that they'll cover.

 

If your insurance has determined $80 (which is the common amount I see) is their "allowed amount" per session, that's what will apply towards your deductible. Then at a 50% coinsurance rate, your insurance company will still only reimburse you up to $40, no matter what the therapist's fees are. 

So if your therapist's fees are $175, you'll apply $80 to your deductible for each session until you reach $1500 and then will only be reimbursed $40 per session after that. 

To break that down: You will have to pay for 9 sessions at $175 out-of-pocket in order to reach your deductible (9 x $175 = $1575). After that you'll receive $40 reimbursement per session, so your cost will be $135/session. 

We did it! Ok, here are the specific questions to ask ...

"Meditation," 1937, René Magritte

Here are the questions to ask when you call your insurance company:

Some of these you may get clear answers, some you may get the run-around.  It kind of depends who you get on the phone. The only way to tell for sure about your reimbursement rate is to submit a claim and see how it goes.

  • What is my out-of-network deductible for outpatient mental health? How much of my deductible has been met this year?

 

  • What is my out-of-network coinsurance for outpatient mental health? 

  • What is the "allowed amount" (or "usual & customary rate") in my area?

 

  • Are these CPT codes covered? 90834 (for Individual Therapy), 90847 (for Couples Therapy)

  • Are there diagnoses that this policy will not cover? 

  • Is there a limit to how many mental health visits I may receive per calendar year? 

  • Do I need an authorization for my visits? 

  • What is the procedure and address to submit a superbill for out-of-network reimbursement?