Insurance can be a confusing topic for many people, even those of us who work with insurance companies every day! One tough part about finding therapy can be sorting out what is covered by your insurance and what you will be responsible for. While so many other factors also matter when searching for a therapist, this is one we can’t afford (literally!) to ignore. It can be scary to need to use benefits that you don’t fully understand. Sometimes understanding your coverage and how it impacts you can help with those feelings; I’m hoping to break down some of the main pieces to understanding insurance coverage here, so that you can feel more knowledgeable and empowered.

Let’s start with some common insurance vocabulary:

• Premium: This is the amount of money that you pay each month in order to have your insurance. It is sort of like a membership fee.

• Subscriber: This is the person who carries the plan. If you have your own plan, like one that you got from work or bought on the Health Connector, you are likely the subscriber. If you are using someone else’s plan, like a plan that a parent or spouse has from work, that person is the subscriber.

• Deductible: Some plans require you to pay for a certain amount of medical expenses on your own before they start coverage. This means that insurance won’t pay for services until you have “met your deductible” (paid for services on your own until the total paid for the year matches the deductible). For example, if you have a deductible of $2000, you are responsible for paying all of your medical bills until those bills have reached $2000. One thing to note here, is that insurance sometimes has a deductible that applies to some services but not others. I occasionally see mental health as being exempt from the deductible; in these cases, insurance starts coverage on these services right away, regardless of whether or not you have met your deductible.

• Copay: If you don’t have a deductible, or if you have already met it, you likely have a copay. This is a set amount that you pay at each appointment, and is a portion of what your insurance allows us to be paid for a given service. For example, if your insurance’s pay rate is $100, they may pay $80 per session and you will be responsible for the leftover $20 per session. Copays vary quite a bit from one plan to another, and I personally have seen copays anywhere from $10-$40 per session.

• In-Network Provider: An in-network provider is one who has signed a contract with a given company to accept the pay rate that that company determines, and follow other guidelines and responsibilities. Insurance tends to have better coverage for providers that are in-network, so most people try to look for a provider who is in-network first. With these providers, you would generally be responsible for deductibles and copays. When you ask if someone “takes your insurance,” you are essentially asking if they are in-network with your insurance.

• Out-of-Network Provider: This is a provider who has not signed an agreement with your insurance company, so insurance may or many not cover them. Some insurance companies have out-of-network benefits, which means that they might reimburse some services done by an out-of-network provider. However, this works a little differently from when you have an in-network provider. For an out-of-network provider, you are responsible for paying the provider directly for their entire bill. The provider can then give you a special receipt, called a superbill, which you can then submit to your insurance company. They use the information on the superbill to determine if they are going to cover the service, and if they decide to do so, they will send you some reimbursement for what you paid the provider. One thing to keep in mind is that they often only reimburse for some part of the expenses, not necessarily the entire bill. For example, if an out-of-network provider charges $100 for a service, you would pay the provider $100 directly. You could then ask them for a superbill, which you would send to your insurance company. Your insurance company might then send you a check for some piece of that (e.g. $60, $70, etc.). Working with out-of-network benefits can feel tricky, but it can be a great way to be able to work with a provider who otherwise does not take your insurance (isn’t in-network).

• Self-pay: This generally refers to someone who is paying for a service on their own and is not using insurance in any way. So if a service is $100, you typically pay the $100 on your own and do not seek reimbursement from an insurance company. This can be helpful if you want the privacy that comes with not using your insurance, or if you have an out-of-network provider who does not provide superbills.

• Sliding Scale: Some providers offer a sliding scale to self-pay clients. This means that the provider has a set fee, but they might allow you to pay an agreed upon amount that is less than this fee based on your financial circumstances. This doesn’t happen if you are using insurance, because when we sign an agreement with an insurance company, we are agreeing to collect the copay/deductible that we are told to.

Insurance can be confusing, but when you understand your own plan, it can make it easier for you to find the care that you need, and understand how much you would be financially responsible for. One of the best ways to find out this information about your plan is to call your insurance plan directly. They typically have a “member services” number located on the back of your insurance card. If you are looking for therapy, you can ask them things like:

1. Do I have a deductible? And does that deductible apply to outpatient psychotherapy sessions?

2. How much is the copay that I am responsible for?

3. What are my out-of-network benefits?

   • If you decide to work with an out-of-network provider, you also might want to ask for the address where you will need to send superbills.

Finally, a couple last notes about insurance coverage:

• Always make sure you understand your benefits. Some therapists will check your benefits for you, but sometimes the information that we receive from your insurance company is inaccurate. It is helpful for you to know what your benefits are, so that you aren’t confronted with the unpleasant surprise of an unexpected bill.

• In terms of therapy services, insurance only covers time that you are in session. Some therapists charge for things like late cancellations or excess time completing paperwork that you ask for (letters, applications for other services, etc.). These are not covered by insurance, so you are fully responsible for those charges. Therapists usually write if and how much they charge for these things in the paperwork that you complete when you first start working with them.

• Insurance can work really well sometimes, and can be a struggle in others. You can minimize that struggle by providing information that your provider asks for, and updating them when your insurance changes. There is a limited timeframe in which we can bill for a service, so if you change plans or identifying info such as your address and don’t notify your provider, any bills they send to your insurance company will be rejected. If we don’t receive the correct information from you in a timely manner, we may miss the billing timeframe and insurance will not cover those services. That means that you would be responsible for the entire bill. So please collaborate with your provider and keep them in the loop on changes — it will benefit you in the end.

I am planning to do some other posts related to insurance, fees, etc. Please send your questions and I will compile them into an anonymous FAQ. You can use the contact form on my website, or send me an email at denisebuckinghamlicsw@gmail.com. I look forward to hearing from you!