You found a therapist who seems right. Their approach fits, they have openings, and then you learn they do not take your insurance. Learning this stops a lot of people from moving forward, and it does not have to.
Out-of-network reimbursement means paying your therapist directly and then asking your health plan to pay you back for part of the cost. Plenty of plans cover some out-of-network mental health care, and cost remains one reason about half of adults with a mental illness went without treatment in the past year.
We put this guide together to walk through how reimbursement works, what to ask your insurer, and what to do if a claim is denied.
What Does Out-of-Network Therapy Mean?
An out-of-network provider is a therapist who has no contract with your health plan. In-network therapists accept a set rate from your insurer as full payment. Out-of-network therapists have not agreed to that, so they set their own fee and ask you to pay it at the session.
That does not automatically mean your plan pays nothing. Many PPO and POS plans include out-of-network benefits, while HMO and EPO plans often do not outside of emergencies. The only reliable way to know is to read your plan documents or call and ask.
Why Are So Many Therapists Out of Network?
Staying in network is often financially difficult for a small practice. The National Academies review found that administrative burdens such as credentialing, billing, and prior authorization matter at least as much as the payment rates. Most therapists work alone or in small groups without billing staff.
Federal parity law is meant to narrow this gap. The Mental Health Parity and Addiction Equity Act generally requires plans that cover mental health care to apply limits no more restrictive than those on medical and surgical care, and network standards fall under that rule. Parity does not require a plan to offer mental health benefits, and it has not closed the network gap.
Curious what kind of therapist would be right for you?
We’ve helped over 500,000 find a therapist that fits for free.
How Does Out-of-Network Reimbursement Actually Work?
You pay at the session, your therapist gives you a superbill, you send it to your insurer, and your insurer applies your plan’s rules and sends you a check. What you get back depends on three things.
Your Out-of-Network Deductible
A deductible is the amount you pay yourself before your plan starts paying its share, and many plans set a separate, higher one for out-of-network care. Until you meet it, your reimbursement is usually zero, though submitted claims still count toward reaching it, so keep sending them.
The Allowed Amount and Your Coinsurance
The allowed amount is the ceiling your plan sets for a covered service. For out-of-network care, plans often build that ceiling from what providers in your area typically charge for the same service, sometimes called the usual, customary, and reasonable rate.
Your coinsurance is your share, written as a percentage of that allowed amount. If your plan covers 60 percent of a $120 allowed amount, it pays $72 and you’d pay the remaining $48.
Balance Billing
When a provider charges more than the allowed amount, you generally pay the difference yourself, in addition to your percentage of the coinsurance This is called balance billing. Federal surprise-billing protections mostly cover emergencies and care at in-network facilities, so they usually do not apply when you choose an out-of-network therapist on purpose.
What Is a Superbill?
A superbill is an itemized receipt from your therapist. It lists your session dates, the service codes, a diagnosis code, the fee you paid, and your therapist’s license and tax details. It is what your insurer needs to process an out-of-network claim.
Most therapists provide one on request, often monthly, and some submit claims for you. Ask during your first session.
If you do not plan to use insurance at all, you can ask for a good faith estimate instead. Providers generally must give uninsured or self-pay individuals a written estimate of expected charges before scheduled care.
What Should I Ask My Insurance Company First?
Make one phone call to save yourself from guessing or being surprised. . Ask these questions and note the call reference number.
- Does my plan include out-of-network outpatient mental health benefits?
- What is my out-of-network deductible, and how much of it have I met this year?
- What is the allowed amounts for CPT code 90837, a 60-minute individual therapy session, and CPT code 90834, a 45-minute individual therapy session?
- What percentage of the allowed amount does the plan pay once my deductible is met?
- Is there a session limit each year, and does anything require prior authorization?
- How do I submit a superbill, and how long does reimbursement usually take?
What If My Claim Gets Denied?
Many denials come down to a missing code or a request for more information. Your first step is an internal appeal, which asks your plan to review its own decision. You generally have 180 days from the denial notice to file, and plans generally must respond within 60 days for care you already received.
If that does not resolve it, you can usually request an external review by an independent third party. Standard reviews are generally decided within 45 days, and insurers generally must accept the reviewer’s decision. Many states also run a consumer assistance program that will help you file at no cost.
How Do I Find a Therapist I Can Afford?
Cost is one part of fitand what therapy typically costs varies widely by region. Here are a few useful places to start looking:.
Your Insurance Company’s Directory
Start with your plan’s directory of in-network therapists, and our guide to finding a therapist who takes your insurance covers that search in depth. Directories go out of date quickly, so call before assuming someone is unavailable. If several are not taking new clients, keep a record of who you called, since network adequacy is one of the standards or parity rules.
Mental Health Match
We created Mental Health Match to make this part easier, and it is free to use. You answer a few questions about yourself and what you are hoping for, and we introduce you to therapists who fit. Profiles include each therapist’s approach, specialties, and fees, so you can weigh cost alongside everything else that matters to you. You can start with a few questions whenever you are ready.
Sliding-Scale and Community Options
Many therapists hold a few sliding-scale spots, where the fee is set by your income. Community mental health centers, university training clinics, and federally qualified health centers often charge less. Your primary care provider may also know local therapists.
| Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. It is also not insurance, tax, or legal advice, and your own plan documents govern your coverage. Always talk to a qualified healthcare professional about any medical concerns. If you are in crisis, please call or text the 988 Suicide & Crisis Lifeline at 988. |
