How To Understand Out-Of-Network Benefits For Therapy

Finding the right therapist can be more challenging than dating. Finding the right therapist who takes your insurance? That’s like one of those urban legends about someone falling in love on their very first Tinder date. Hold out for that dating app dream scenario if you want, but if you’ve given up on finding a therapist who accepts your insurance, it might be time to investigate your out-of-network benefits.

Of course, not everyone has out-of-network benefits — but if you do, you can use them to help cover the cost of treatment from providers who aren’t in your insurance network. This often means the insurance company will cover less than if the provider were in your insurance network, so you may have to pay more money. (Note that the amount that you’re covered could vary widely depending on your plan.) But the benefit to you is more flexibility in choosing providers — which can be particularly helpful when searching for a new therapist. “I think it’s important that people use their insurance benefits to the fullest and also work with a provider that fits their needs and they feel comfortable with,” says Diana Gasperoni, LCSW-R, founder and CEO of BeWell Psychotherapy, a psychotherapy group practice in New York City and Hoboken, New Jersey. “If you’re using out-of-network benefits, you may have to do a little more investigation.”

Here’s what to know before you schedule your first out-of-network session.

What’s the difference in cost?

Therapy costs range from an estimated $65 an hour to upward of $200. Cost is based on multiple factors, including where the therapist is located, the therapist’s training, and whether the therapy has a specialty: Specialization in certain disorders or treatments may be more expensive. In general, an in-network provider will be less expensive for you, because you’ll only be responsible for a co-pay. (For example, if a therapist charges $200 per session, but your co-pay for specialist appointments is $50, you’ll only pay $50.) But sometimes, it might be hard to find a provider who takes your plan, who has availability, who has hours that are convenient for you, or whom you click with. There may also be a cap on how many sessions are covered.

Therapists, too, may have different motivations for going the out-of-network route. In-network therapists have to handle the administrative red tape of dealing with insurance companies, for example, and they may not be reimbursed as much by insurance companies as they would be with private pay patients.

For all of these reasons, seeing a therapist who takes out-of-network benefits may make the most sense. But this does mean you might be paying more money for therapy. “Someone seeking therapy should keep in mind that the cost of therapy is an investment in yourself,” says Gasperoni. “You’re paying for the experience and training of the person you have chosen to support you on the path to mental health wellness.”

How do you know what kind of out-of-network coverage do you have?

Unfortunately, you're going to have to make some phone calls.

Research what out-of-network benefits your insurance offers for therapy. This will vary from plan to plan. In some cases, you may only be covered for out-of-network care once you have reached your deductible. Plans can be confusing to navigate; call and ask for clarification if you don’t understand the terms on your provider’s website. Once you know your coverage, you will then have a better idea of how much you will need to pay your provider. Don’t assume your co-worker has the same coverage — even if you think you’re on the same plans. “Each insurance company and each policy within the insurance company has a different rate for a therapist’s service,” explains Gasperoni.

You might find the co-insurance rate listed. This is how much you’ll be responsible for paying and how much insurance will pay. For example, let’s say you have 50% co-insurance. That means you’re responsible for paying 50% of the session fee, and your insurance will cover the rest — meaning a $200 appointment will cost $100 out of pocket. But co-insurance often doesn’t kick in until your deductible is met. Your deductible is the amount you have to pay for covered services. This is across medical appointments, not just therapy, which means doctor’s visits may also go toward reaching your deductible. But — another heads-up — deductibles may be different based on whether you are using out-of-network benefits or in-network benefits. But if you have a $1,000 deductible, you’ll be responsible for covering the full $200 — or whatever your session fee might be — out of pocket.

And your deductible resets each year. If you’re regularly seeing a therapist, that means you might have to budget more money for therapy in January, and then you’ll be paying less for each session as the year progresses.

Another thing to ask your insurance company as you’re understanding your coverage: if there’s an annual limit to the number of sessions you can have or if there’s a limit on how much you can be reimbursed. This will also impact how much you’ll likely pay for sessions throughout the year.

But in general, unless you’ve already met your out-of-network deductible, your first sessions are likely to be whatever the provider bills, and you likely won’t get any reimbursement.

What questions should you ask your provider?

Providers may approach out-of-network benefits in two ways, says Gasperoni. The first way is that you’ll be entirely responsible for submitting your claim and being reimbursed to the insurance company. You’ll pay the full cost of therapy after your session, and your therapist will give you a superbill — a type of medical invoice that includes information such as date of the appointment, diagnosis code, and the CPT code — the type of treatment you’ve been given, like a 45-minute psychotherapy session. Other providers might help you with billing.

“In our practice, we offer in-house billing,” explains Gasperoni, who adds that this means the therapist will submit the claim on your behalf. Once your therapist verifies your benefits, they will be reimbursed directly by the insurance company, and you’ll be responsible for any out-of-pocket costs. There are also services that can do this work for you. For example, Advekit is a platform that connects you with out-of-network therapists, doing the work of billing and allowing you to pay what you owe.

What if you can’t afford what your therapist is charging?

If out of network benefits are a stretch to your budget, talk with your therapist. “In some cases therapists offer a reduced rate for their services. They may have a percentage of their practice that they see at a reduced fee,” explains Gasperoni, who adds this is sometimes called “sliding scale.” They may also have a referral to someone who works on a sliding scale. This doesn’t mean you’ll receive subpar service — it could mean that you are working with someone at the beginning of their career, who is being closely supervised. “Interns can be a great option,” says Gasperoni. “They are enthusiastic and get lots of supervision — so a senior therapist with loads of experience is looking over everything they do. In our practice, some clients see a clinical intern for as little as $25 a session.”

There also may be therapy training centers or universities that offer mental health degrees, which may have a low-cost clinic where clients can see therapists who are still in training. Ask around or Google low-cost therapy near you and see what you find.

Are there lower-cost options for therapy?

There are some workarounds here. Maybe you see your therapist every other week instead of once a week. Or maybe you figure out a way to shift your budget to prioritize therapy for a few months. If your family is in a position to help and you feel comfortable doing so, you may also ask if they’d be willing to contribute. There are also grants available for therapy. For example, The Loveland Foundation has grants for Black women and girls who would like financial assistance for therapy.

Your employer may also offer short-term therapy through its employee assistance program (EAP). This is typically a short-term model, where employees receive three to five covered sessions. But utilizing the EAP may help you find referrals for therapists who can work with your budget. Similarly, if you’re in school, your school may have a counseling center with free or low-cost therapy sessions.

You also may find group therapy less expensive than seeing a therapist one-on-one. You also may consider using an online therapy app or platform, but these may have pros and cons.

When you’re paying so much money for treatment, it’s important that you feel it adds value to your life. That’s not to say every session should be as relaxing and worry-free as a trip to the spa (even if that’s how much it costs!), but overall, you should feel like therapy is helping you through issues and adding value to your life, says Gasperoni. In order to achieve that, you may need to see a few therapists until you find the right fit.

Expert:

Diana Gasperoni, LCSW-R, founder and CEO, BeWell Psychotherapy