Insurance reimbursement for mental health services: Mental health coverage questions to ask
So you think you found the perfect therapist for you, and then you realize that you have no idea how you’ll pay for it. Getting insurance reimbursement for mental health services or even inquiring about your mental health coverage can be confusing, at best. At worst, it can be infuriating and hugely frustrating during a time in which you are likely already on the more emotionally vulnerable side. Here are a few tips from a private pay “out-of-network” therapist so that you can follow these instructions to research and apply for insurance reimbursement for therapy. You deserve to know and understand all of your options so that you get the best chance at a successful therapy experience. Don't be daunted by the paperwork logistics!
Insurance reimbursement for mental health or pay the copay? Which to choose
If you’re searching for a mental health provider, you will quickly find that there are those who accept insurance (one, several, or many) and providers who are considered “out-of-network” private pay practitioners. Neither distinction makes one therapist better or more qualified than the other; it’s simply a matter of you, the consumer, choosing whether to look only at providers who take your insurance OR broadening your search to include providers who do not take insurance but for whose services you may seek insurance reimbursement. Basically, you choose to go directly through insurance (insurance pays the provider directly, you may have a copay to pay as well) or you choose to pay the provider directly and you work with your insurance company to recoup any money you’ve paid to the provider. This happens through an insurance reimbursement process for mental health services. This might sound confusing, but there are ways to make this process easier.
What’s your mental health coverage through your insurer?
Mental health insurance coverage is based on your specific plan, what it covers, your deductible, and the provider offering services. When you’ve found a therapist who you feel is a great fit for you, it can be very daunting to then learn that they do not participate with insurance. However, this does not mean that your mental health coverage would not apply to being covered for seeing them.
Here are a few helpful tips for understanding your mental health coverage through your insurer.
Talk with your Human Resources department:
If you are insured through your employer, they may be the first place to go to talk about insurance reimbursement and mental health coverage. Since they speak the language of insurance plans, they can offer guidance for how to go about researching your mental health coverage, maybe even providing you with a few short-cuts to make the process easier.
Call the number on the back of your insurance card:
When they ask why you are calling (often automated), simply state that you are inquiring about your mental health coverage benefits.
Ask about your deductible as it relates to mental health coverage:
Many times, if you have already reached your deductible, there may be coverage for mental health services provided by out-of-network providers that your insurer will pay up to a certain amount.
If you have not met your deductible, ask about documentation that you can provide to support your claim:
Private pay or out-of-network therapists will often request that you pay them directly but will then provide you with what is called a “Superbill” that you can send to your insurance company as proof that you paid them for services. This will almost always require that your therapist provides a diagnosis, so be sure to talk through this with your therapist.
Ask about reimbursement rates post-deductible:
After you’ve met your deductible, and depending on your mental health coverage within your plan, your insurance provider may provide insurance reimbursement up to a certain percentage of what you paid. For example, if your provider billed you $100 for a 50 minute session, and your insurer reimburses out-of-network visits at 80%, they would then issue you reimbursement for $80. However, rates of reimbursement vary wildly, so you will need to be specific in what you are requesting from your insurer.
An example of how insurance reimbursement for mental health services can work
For many private pay providers, they have elected NOT to work with insurance companies due to the abundance of paperwork needed for submission, a reliance on diagnoses being made, and at times, difficulty getting paid for their services due to disputes over whether or not certain services are covered. Though not always, the process for working with an “out-of-network” mental health provider can often go something like this.
You pay for each session with a credit card on file
After each month’s payments, you receive a “superbill” from the provider for the previous month’s charges (for example, if you meet 4 times in one month that is $500 baked on 50 minute sessions costing $125 each) that documents that you paid
You submit that document to your insurance company so that they apply it toward your deductible
Let’s pretend your deductible is $500. If that’s the case, you meet the deductible right away and they should then (moving forward) reimburse you for a certain percentage of what you paid to me, provided they will reimburse for out-of-network expenses. The percentage of what they will reimburse varies depending on your insurance plan.
Still pretending the deductible has been met, pretending that they reimburse at 75%, they would reimburse $93.75 per $125 session.
Again, all of this depends on your deductible, your plan, and what they determine the “rate of reimbursement” to be for an out-of-network provider. Insurance reimbursement for mental health services is not an impossibility, it just takes good communication, research, and likely some collaboration with your practitioner.
Why go through insurance reimbursement for mental health services versus choosing someone who accepts my insurance?
If you’re willing to do the work for insurance reimbursement rather than simply opting for a provider who accepts your insurance, you will have access to a far wider range of providers, areas of expertise, telehealth versus in person options, etc. Having more options will allow you to find someone with whom you really connect which will likely make the time spent in therapy shorter and more meaningful rather than going simply with who’s covered, regardless of “fit” with your needs.
Using the same example as above, and provided you’ve met your deductible and are being reimbursed for nearly $94 or a $125 session, you essentially just paid $31 for therapy services, which is comparable to the copay required by many plans, and yet you were able to be more “picky” about who you wanted to work with.
By paying for the session up front and then doing the legwork to recoup what you paid for therapy, your insurance coverage has allowed you greater flexibility in choice of therapist, though it admittedly may take you a bit longer to be reimbursed for your spending rather than paying a copay up front.
Other ways to request insurance reimbursement for mental health services
New ways of making insurance reimbursement easier are developing all of the time. A new option that exists is an app called Reimbursify that I just learned about that makes the submission of superbills and requests for reimbursement easier, charging the user a small fee for doing the leg-work, electronically.
If they can afford it, clients will sometimes do large insurance reimbursement requests all at one time (say by quarter or year) after having paid up front for sessions throughout the year. Out-of-network providers can issue superbills in whatever way it is easiest for clients, so I will often issue multi-month superbills for clients for reimbursement if they realize that several months have gone by for which they have not requested reimbursement and need one simple (long) document of all expenses incurred. This is an easily generated document that makes it easier for clients to request reimbursement, so I’m always happy to simplify this process for them.
Some clients have Health Spending Accounts (HSA's) that are funds that can be used specifically for medical expenses. Therapy counts! If you're fortunate to have HSA funds, therapy can be a great investment in your overall wellness; and payments made can STILL go toward that aforementioned deductible.
In conclusion, requesting insurance reimbursement for mental health services can be overwhelming, but it can be made easier by following the few basic steps above and doing your research using the script and steps provided. If insurance reimbursement for an out-of-network provider can give you access to a clinician with whom you really connect well, it may be worth the few extra steps of paperwork that could result in overall shorter time spent in therapy and overall fewer dollars spent on mental health services. Your mental health is valuable – don’t shortchange yourself by immediately eliminating options who don’t accept your insurance.
