Using out-of-network benefits for therapy

Many insurance plans will reimburse part of what you spend on therapy with a provider outside their network. Here’s what to know.

How out-of-network reimbursement works

You pay for each session at the time of service, and I give you a detailed receipt (a “superbill”) with the information your insurance company needs to process a claim. You submit it to your insurer, usually through their member website or app, and if your plan includes out-of-network benefits, they reimburse you directly for a portion of the fee.

The reimbursement amount depends on your plan. Most plans have an out-of-network deductible you meet first, and after that they pay a percentage of the allowed amount for a session. For example, if your plan allowed $150 for a session and paid 70% after your deductible, you’d be reimbursed $105 of a $200 session. Those numbers are only an illustration, and a call to your insurer will tell you your own.

What to ask your insurance company

Call the member services number on the back of your card and ask about outpatient mental health benefits with an out-of-network provider.

  • Do I have out-of-network benefits for outpatient psychotherapy?

  • What is my out-of-network deductible, and how much of it have I met this year?

  • After the deductible, what percentage do you reimburse?

  • What is the allowed amount for CPT code 90837, a psychotherapy session of 53 minutes or longer?

  • Do I need pre-authorization, and is there a limit on the number of sessions?

  • How do I submit a claim, and is there a deadline for submitting it?

What a superbill shares with your insurer

It’s worth knowing what goes to your insurance company when you submit a claim, so that you can decide if it’s a fair trade for the reimbursement. A superbill includes your name, date of birth and insurance information, the dates of your sessions, the type of service, and a diagnosis code, because insurers reimburse only for care they consider medically necessary. It doesn’t include anything about what we talk about.

If you’re paying privately

Weekly sessions are $200. Therapy is generally an eligible expense for a health savings account (HSA) or flexible spending account (FSA). If your employer offers an FSA, fall open enrollment is a good time to set aside money for the year ahead. Before we begin, you’ll receive the mandated Good Faith Estimate of your expected costs.

Questions about cost?

If you’re not sure what your plan covers or which questions to ask, bring it to a free 20-minute consultation. We can look at it together before you decide anything.

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FAQ

  • Usually not. Reimbursement is based on your plan’s allowed amount and your coinsurance, so most people get back part of the fee rather than all of it. Your insurer can tell you the numbers for your plan.

  • Generally yes, once you submit the superbills: they count toward your out-of-network deductible, which is often separate from your in-network one. It’s worth confirming with your insurer.

  • HMO plans, which include many Kaiser plans, often don’t cover out-of-network care at all, so check before counting on reimbursement. Many people in that situation pay privately or use an HSA or FSA.

  • No. Insurance doesn’t cover intensives, so they’re self-pay, and some plans I’m in network with don’t allow their members to pay privately for one either. If you have insurance and you’re interested in an intensive, tell me your plan in the consultation and I’ll let you know where you stand. More on the EMDR intensives page.

  • For out-of-network care, you submit the superbill yourself. It usually takes a few minutes through your insurer’s website or app, and I’m glad to help if you get stuck.