Navigating Insurance For Therapy Guide
Finding the right therapist can be overwhelming to begin with, add in trying to understand the complicated and seemingly nonsensical world of health insurance plans and benefits makes it that much more frustrating. We are happy to help you understand your benefits to make this process as smooth as possible. Here are some frequently asked questions to help you navigate the insurance maze.
WHAT DOES “IN-NETWORK” MEAN?
When your therapist is in-network it means that the provider has signed a contract with your insurance carrier to provide services for an agreed upon standard fee or rate. When they will be able to bill your insurance, your policy will cover their services (if deemed medically necessary) according to your plan benefits and that you will only be responsible for your copay or deductible/coinsurance if you are on a deductible plan. InPowered Therapy is in network with most BCBS PPO and Blue Choice PPO plans and are currently in process of paneling with Aetna.
WHAT IS A COPAY?
A copay is the amount you are responsible for per session when on a plan that uses copays to cover your general. medical appointments. For example, if a session is $150 and you have a $20 copay, that means you only owe the therapist $20 and insurance will pay the $130.
WHAT IS A DEDUCTIBLE AND COINSURANCE?
Some plans use a deductible and coinsurance to cover the cost of medical care instead of having a copay. These plans often have lower premiums, meaning they are less expensive up front, since you are responsible for paying the full contracted rate for medical care until the deductible is met. A deductible is the amount of money you have to pay towards your medical care before your plan will start to pay for part of your services. Once your deductible is met you will only be responsible for the coinsurance rate, or a percentage of the total contracted rate. For example, if you have a $300 deductible and 10% coinsurance that means that after you spend $300 on appointments you will only be responsible for 10% of the session fee from then on.
WHAT IS AN OUT OF POCKET MAX?
An out of pocket max is the maximum amount that you are responsible to pay towards your health care for the plan year. Once this amount you will owe $0 for your sessions until the following plan year (typically January 1st).
* Note: this is often separate for IN-network vs OUT-of network.
WHAT IS AN INSURANCE CARVE-OUT AND WHY THEY IMPACT YOUR CARE?
It is becoming more common to see carve-outs for mental health care meaning that mental health benefits are removed from a policy holder’s coverage, and are provided through a contract with a separate provider or insurance company. In layman’s terms you have insurance company A as your main plan and your insurance card is from that company, BUT in order to save money, they removed coverage for your mental health care and instead provide this through insurance company B (who your provider may not be in network with).
The most common one we see with BCBS primacy plans is to have OPTUM for mental health coverage and we are NOT IN-NETWORK with Optum who is also often known as (United Health Insurance).
WHAT ARE HSA and FSA ACCOUNTS?
Both Health Savings Accounts (HSA) and Flex Spending Accounts (FSA) are pre-tax savings accounts that can be used to pay for qualified medical expenses. These funds are typically attached to a debit card and can be used to pay for therapy and other medical expenses. HSA accounts allow for larger contributions and may allow you to carry unused money over to the next year but you are only eligible if you are enrolled in an HSA-eligible health plan (often these are called “high deductible plans.” FSA accounts have lower contribution limits and you can’t usually carry fund over so they must be used by the end of the enrollment period or those funds are lost.
WHAT DOES “OUT-OF-NETWORK” MEAN, AND HOW CAN I STILL BENEFIT FROM THERAPY IF I AM OUT OF NETWORK?
Being out of network means your therapist has not signed a contract with your insurance company for an agreed upon rate. This often happens because that insurance company either offers low rates for compensation, is difficult to work with, and/or is not allowing more providers on to their network. If your provider is out-of-network you may still be able to have a portion of your services covered by insurance depending on your out-of-network benefits. Your out-of-network benefits usually involve a separate (often higher) deductible amount and it’s own coinsurance percentage. Some plans actually have decent out-of-network coverage so it is worth exploring this as an option if you wish to your insurance and your provide is not in your network. We would be happy to assist you in checking your out of network benefits if you need more information.
WHAT IF I AM NOT IN-NETWORK AND DON’T HAVE OUT OF NETWORK BENEFITS OR THEY ARE SO HIGH THEY WON’T HELP?
We may be able to offer you something called a “sliding scale” This is a reduced fee that does not go through insurance. Our sliding scale options start around $75-$100 per session depending on your clinician and their license level, training, and experience.
WHAT IS A SELF-FUNDED PLAN AND WHY DOES IT MATTER IF I HAVE ONE?
Another trend we are seeing is the increase of “self-funded” insurance plans. What this means is that the insurance company doesn’t actually pay the claims with it’s money, instead are only responsible for processing claims according to the contract with your employer and then the company who is the employer is actually paying the claims. This may seem like an insignificant detail however it can have BIG implications because state laws can not regulate how these plans cover your care like they can for “fully-funded” plans that are paid by the insurance company. This means that the recent legislation protecting telehealth coverage without platform restrictions may not apply to you. Self-funded plans can, and have, started returning to denying telehealth altogether or restricting it to specific platforms that your provider may not be in network with.
*InPowered is NOT In-network with any designated platforms such as MDlive
QUESTIONS TO ASK YOUR INSURANCE PRIOR TO STARTING THERAPY
Is InPowered Therapy (NPI # 1801330048) in-network?
Specify IN or OUT of network for all of the following based on this.
How does my plan cover “outpatient behavioral health,” otherwise known as therapy services (CPT Codes 90834 and 90837)?
Does my plan require pre-authorization for outpatient mental health services?
Do I have a deductible or a copay?
If I have deductible, how much is it?
How much is my co-insurance following meeting my deductible?
What is my out of pocket max?
Is my plan fully funded FF (claims paid by the insurer) or self funded SF (claims paid by your company)?
If your plan is FF your plan falls under IL legislation requirements and thus can not deny or restrict access to Telehealth through platform restrictions.
If your plan is SF your company is allowed to decide how they cover Telehealth and thus can deny it altogether or limit it to particular platforms that we are not part of. (Follow up with following questions related to Telehealth coverage)
Does my plan allow for Telehealth?
Does my plan pay for this service the same as in person services?
Are there restrictions on the platform my therapist uses to offer Telehealth?
