Understanding your health insurance for therapy

Insurance terms can be confusing, especially when it comes to mental health coverage. Here’s a plain-English guide to the terms you’ll likely run into and how they actually work.

What is a deductible? The amount you pay out of pocket before your insurance starts covering sessions. If your plan has a $1,500 deductible and you haven’t met it yet this year, you’ll likely pay the full session rate until you do — insurance won’t contribute anything toward the cost until that threshold is reached.

What is a copay? A fixed amount you pay per session once your deductible is met (e.g., $25 per visit), with insurance covering the rest of the negotiated rate.

What is coinsurance? Instead of a flat copay, some plans have you pay a percentage of the session cost (e.g., 20%) after your deductible is met, rather than a set dollar amount.

What’s the difference between in-network and out-of-network? I currently accept [list her actual in-network plans]. If your plan isn’t listed, you may still have out-of-network benefits — meaning your insurance reimburses you a portion of what you pay me directly, even though I’m not contracted with your specific plan.

How do out-of-network benefits actually work?

  1. You pay the full session fee upfront. Since I’m not contracted with your plan, you pay me directly at the time of service. Contact me for pricing DL@deniselucaslpc.com
  2. I give you a superbill. This is an itemized receipt containing what your insurance needs to process a reimbursement claim: my license number, NPI number, the CPT procedure code for the session, a diagnosis code, the date of service, and the amount you paid.
  3. You submit the superbill to your insurance company yourself — usually through your plan’s online member portal, a mailed claim form, or fax. The exact process varies by insurer, so check your plan’s specific submission method.
  4. Your insurance applies it against your out-of-network deductible. This is typically a separate, and often higher, deductible than your in-network one. Until you meet it, each submitted superbill just reduces that remaining balance — you likely won’t see reimbursement yet.
  5. Once your deductible is met, you’re reimbursed a percentage of the “allowed amount” — not necessarily a percentage of what you actually paid. Insurance companies typically decide what they consider a reasonable rate for a given service in your area (sometimes called the “usual and customary” rate), and reimburse a percentage of that number. If they determine $130 is reasonable and your plan covers 70% out-of-network, you’d get back $91 — even though you paid $175. This gap between what you pay and what’s reimbursed is sometimes called balance billing, and it’s the main reason out-of-network reimbursement often comes in lower than people expect.
  6. Reimbursement arrives directly to you as a check or direct deposit from your insurance company, typically several weeks after you submit the superbill — it’s not an immediate discount at the time of your session.

What should I ask my insurance company before my first session? Call the number on the back of your insurance card and ask:

  • Do I have mental health/behavioral health outpatient coverage?
  • Do I have a deductible, and how much of it have I met this year? (Ask about both your in-network and out-of-network deductible if applicable.)
  • What’s my copay or coinsurance for outpatient mental health visits?
  • Do I have out-of-network benefits for mental health services, and if so, what percentage of the allowed amount is reimbursed?
  • Is prior authorization required for outpatient therapy?
  • What is the reimbursement rate for CPT code 90837 or 90834 (standard outpatient therapy session codes)?

Is what my insurance tells me over the phone a guarantee of coverage? No. Whatever your insurance company tells you during a verification call is considered an estimate of benefits, not a guarantee of payment. Insurance representatives are giving you the best information available at the time of the call, based on your plan as it exists that day — but actual coverage and reimbursement can still change by the time a claim is actually processed, due to factors like:

  • Changes to your plan that take effect between your call and your session
  • How your specific diagnosis or treatment is coded
  • Your deductible status changing if you’ve had other medical expenses in the meantime
  • The insurance company’s own internal review of the claim once submitted

In other words, someone telling you “yes, this is covered” over the phone is a helpful starting point, but it isn’t a binding promise from the insurance company that they will actually pay that amount. You’re always financially responsible for the cost of services regardless of what an initial verification call indicated, if the claim is later processed differently than expected.

A note on cost Even with insurance, mental health coverage varies significantly by plan — it’s worth calling ahead so you’re not surprised by the bill. I’m happy to answer general questions about how this process works during your free consultation, though for exact numbers specific to your plan, your insurance company will always have the most accurate answer, understanding that even that answer isn’t a guarantee.

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