Insurance can make the impossible possible but on the other hand be nearly impossible to comprehend. Rates, fee schedules, deductibles, co-insurance, copays…it can be a lot to take in! Here are some insights and a few helpful tips for navigating your coverage.
Rates: It’s all just counseling right? Wrong.
Insurance rates are determined by the type of service being provided. For example, mental health counseling may begin with a Psychiatric Diagnostic Assessment. The following counseling sessions may be Individual Psychotherapy or Family Psychotherapy. There are quite a few other common types of services as well. It is important to understand each visit is associated with a code (or multiple codes) which determines the amount of money the insurance company will remit to the service provider.
In-Network vs. Out-of-Network Providers:
An in-network therapist has a contract with your insurance provider to render services for specific rates. In-network therapists have been through a vetting process by the insurance company; though this process varies widely and is not necessarily a metric for quality of services.
Don’t write-off out-of-network providers. Depending on availability in your area for certain specialties you may find an out-of-network provider to be a solid option. Though out-of-network services can place more of a financial burden on you, some benefits from your insurance company may still apply.
You should speak directly with an insurance representative to get clear expectations before using either in-network or out-of-network service providers.
Deductible:
Your insurance plan may have a deductible, a threshold you must meet through payments to service providers in order for the insurance benefits to be applied to your bills. For instance, if you have a deductible of $1000.00 you will be responsible for 100% of your medical bills until you have paid a total of $1000.00. Once you have met the deductible your insurance benefit will begin to be applied to future invoices.
Co-pay:
A co-pay is a set fee you are responsible for at each visit (or per service). This can range from a few cents to a couple hundred dollars. Typically for behavioral health these fees are from $5.00 to $25.00 for outpatient office visits. Co-pays can be required in addition to other fees or be your sole obligation; this is all dependent on your insurance plan.
Coinsurance:
Represented by a percent (%) coinsurance is the portion of your bill for which you are responsible. Coinsurance typically relates to plans with a deductible and delineates the amount insurance providers will cover versus how much the consumer pays. Common plans may be reflected by terms such as “70/30” for example. In this type of plan, once the customer has met the deductible the insurance company will pay the service provider 70% of the service rate and the customer is responsible for the remaining 30%.
Still confused?
In most cases, you (the consumer) are ultimately responsible for payment of services rendered. Always refer to your insurance plan documents and if needed call your insurance provider via the phone number listed on your insurance card.
Questions for your Insurance Provider
- Do I have mental health/behavioral health coverage?
- Does my plan cover virtual therapy (telehealth)?
- Do I have a deductible that needs to be met before insurance will pay towards services?
- Do I have a copay and/or coinsurance per visit? If so, what is the amount?
- How many sessions does my insurance cover?
- Is approval from my primary care doctor needed before starting counseling?
A Few Final Tips:
Insurance jargon, false or misleading information, and varying information can all make navigating your benefits a nightmare. It is best to try to understand your benefits prior to ever needing them as the stress of needing a service can make last minute preparations exponentially more daunting.
Whether reviewing your insurance documents or talking with a representative, write notes that are easy for you to understand and reference at a later date.
Understand high healthcare costs within a given year may be eligible as a tax deduction. Talk with your financial planner or tax advisor to understand how tax laws apply to your particular situation.
Finally, talk openly with your provider about the costs of services and gain clear insight into your financial obligation. Access to Behavioral Health should not be a financial burden but sometimes the expenses can be a deterrent from seeking services.
Depending on laws and ethics providers may not be able to openly offer discounted services or optional forms of payment; however, it can be worth your time to ask about other options, recommendations, or referrals. Whatever it is you are dealing with…you don’t have to face it alone!