NAVIGATING INSURANCE

Navigating Insurance can be confusing! All plans are different. The best way to find out what your plan does or doesn’t cover is to log into your patient profile online or call the number on the back of your card. If you get your insurance through an employer, contact HR to explore changing your insurance plan or to learn about other employer-led healthcare benefits, like an FSA.  These are some common insurance terms & how they typically apply to mental health care. Below, there are tips for making therapy more affordable and navigating using out-of-network benefits.

COMMON INSURANCE TERMS

Deductible

the amount you have to pay before your insurance will start covering your care. Some plans require you to meet your deductible before they cover mental health care and others don’t.

Co-pay

the amount you pay for every service. This amount varies widely depending on your plan and the type of care you’re getting. Co-pays for mental health therapy typically range from $0-$60.

Co-insurance

The patient is responsible for covering a percentage of the cost of care. The insurance company will cover the rest. Co-insurance varies widely by plan, but the patient responsibility is typically between 20% and 60%. This is more common with out-of-network benefits.

Premium

the amount you (and/or your employer) pays the insurance company each month to ensure your benefits.

In-network

When a provider is in-network, they agree to provide services at a discount (the “allowed amount”) in exchange for referrals from the insurance company. Typically, your provider will bill your insurance company for your services, and you will only be responsible for covering your deductible, if it applies, and your co-pay, if you have one. Your insurance company will reimburse your provider for the remainder of the “allowed amount.”

Out-of-network

When a provider is out-of-network, they don’t have any agreements with your insurance company and don’t provide services at a discount. Typically, you are responsible for covering the cost of therapy up-front and must submit receipts (sometimes called Superbills) to your insurance company so that your insurance company will reimburse you, according to your plan benefits.

HSA (Health Savings Account)

This is a tax-advantaged account that helps folks with high-deductible health plans cover the costs of their care. You can use it to cover deductibles, co-pays, co-insurance, prescription, and some medical devices, but not premiums. Some insurance companies offer HSAs for their eligible plans, or you can start an HSA as an individual. Learn more about HSAs.

FSA (Flexible Savings Account)

This is a tax-advantaged account that is set up by your employer that you can use to pay for co-pays, co-insurance, deductibles, prescriptions, and some medical devices. Learn more about FSAs.

A note on diagnoses

Insurance companies require your therapist to give you a mental health diagnosis to cover any mental health treatment, which means many therapists give a diagnosis after they meet you the first time. Diagnoses can change, but any diagnosis you receive will become part of your health record. Ask your therapist about their approach to this, if you have concerns or questions about it. 

How your therapist’s license impacts insurance

Some insurance companies will only cover therapy that is provided by fully licensed clinicians. Fully licensed means your therapist has worked for at least 2 years, received clinical supervision in diagnosing and treating mental health disorders, and passed a licensing exam. Your therapist will be able to tell you if they’re fully licensed. If they’re not and you’re using OON benefits, you may want to call your insurance company to verify your coverage. 

TIPS FOR MAKING THERAPY MORE AFFORDABLE

Fund an HSA, if your plan is eligible

You won’t pay any taxes on the money you put into your HSA, you can use it to cover many healthcare costs, the money you put in it never goes away, and you can invest your funds. 

Fund an FSA if your employer offers one

You won‘t pay any taxes on money you put in an FSA, and you can use it to cover many healthcare costs. FSA funds can’t be carried over year-to-year so you’ll want to estimate your costs before funding.

Choose a plan with OON benefits*

*This will save you money if your provider is OON, but can be more expensive than a plan with no OON benefits. Check with HR or your insurance provider to learn about your options.

Choose an in-network provider

If one is available, you’ll save money by going in-network. For therapy, you’ll have more options if you’re able to use OON benefits. 

Consider therapy frequency

Bi-weekly or monthly therapy can be supportive for many goals. 

Consider a coaching or therapy group

Group options are often more affordable and can be a great support in addition to or —for some goals— instead of individual therapy. 

USING YOUR OUT-OF-NETWORK BENEFITS

If your provider is out-of-network, that typically means: 
1) You’ll pay for the cost of therapy upfront.
2) Your therapist will provide a receipt (often called a Superbill) with all of the necessary information.
3) You’ll submit the receipt to your insurance company. 
4) The insurance company will reimburse you for a percentage of the cost of your care.

Some therapists are able to submit Superbills on your behalf or work with a services that does. Ask your therapist how they handle this process.

At ROAR, we work with a service called Thrizer that will submit on your behalf or we can provide a Superbill if you’d rather do it on your own. 

To find out about your OON benefits, call the number on the back of your insurance card and ask: 

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

• What is my co-insurance responsibility for outpatient mental health? Is it the same for telehealth?

• How do I submit claim forms for reimbursement?

• Is there a deadline for reimbursement?

• Do I need a referral from an in-network provider to see someone out of network? 

• Do I need any other prior authorization to receive these benefits? 

• Is there anything else I need to do to use benefits for outpatient mental health?