Most Anthem plans generally cover therapy, but the details depend on your specific plan. Anthem offers different types of coverage through employers, the Health Insurance Marketplace, Medicaid, and Medicare, with benefits varying by plan and state.
This means two people with Anthem insurance may have different provider networks, out-of-pocket costs, and requirements for accessing care. What is covered under one person’s plan may not be covered under another’s.
This guide explains what Anthem plans typically cover, what costs you might expect, and how to check your benefits before scheduling your first therapy appointment.
Does Anthem Cover Therapy?
Generally yes, and for many plans it is not optional. All Marketplace plans must cover psychotherapy and counseling as an essential health benefit, along with inpatient mental health services and substance use disorder treatment.
Employer plans work a little differently. They are not required to offer mental health benefits, though nearly all do, and when they do, federal parity rules govern how those benefits compare to medical coverage.
What varies is usually not whether therapy is covered. It is which therapists are in your network, how much you pay, and whether anything needs approval first.
Why Does the Answer Depend on Which Anthem Plan I Have?
Anthem is a family of plans rather than a single product. Anthem Insurance Companies serves a defined list of states, and in a couple of them only certain counties, so the networks and plan rules shift with geography.
Plan type matters just as much. An HMO, a PPO, a Marketplace plan, a Medicaid plan, and a Medicare Advantage plan can each handle referrals and cost sharing differently under the same brand name. When you look up coverage details, make sure they match your plan and your state.
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What Mental Health Services Are Usually Covered?
For plans subject to essential health benefit rules, three categories must be covered:
- Behavioral health treatment, such as psychotherapy and counseling
- Inpatient mental and behavioral health services
- Substance use disorder treatment
Beyond that baseline, plans commonly cover virtual therapy visits, intensive outpatient programs, crisis services, and medication management through the pharmacy benefit. Anthem’s Ohio Medicaid plan, for example, lists outpatient counseling, inpatient care, crisis services, and intensive outpatient treatment among covered services.
Your benefits depend on your state and the plan you chose, which is why two Anthem members can get different answers to the same question.
Do I Need a Referral to See a Therapist?
Whether you need a referral depends on your specific Anthem plan. Checking your plan’s requirements before scheduling can help you avoid unexpected costs.
Referral requirements vary by plan. Some plans require referrals for certain services, while others allow members to schedule outpatient mental health appointments directly. Many plans do not require a referral for behavioral health at all. For example, on Anthem’s Ohio Medicaid plan, members do not need a referral from a primary care provider to see an in-network behavioral health specialist.
Prior authorization is a separate question. Routine outpatient therapy often does not require it, while higher levels of care such as inpatient or residential treatment frequently do. Parity rules limit how differently a plan can apply those requirements compared with medical care.
How Do Costs Work With Anthem?
Your out-of-pocket costs depend on your specific Anthem plan. Understanding these four common insurance terms can help you know what to expect when paying for therapy.
- Deductible. The amount you pay for covered services in a plan year before the plan starts paying its share.
- Copay. A fixed amount you pay for a visit, such as a set charge for each therapy session.
- Coinsurance. A percentage of the cost of a visit that you pay, usually after you have met your deductible.
- Out-of-pocket maximum. The most you pay for covered, in-network services during a plan year. Once you reach this limit, your plan generally pays 100% of covered, in-network costs for the rest of the plan year.
Therapy costs vary depending on your Anthem plan and can change from year to year. Seeing a therapist who is in your plan’s network generally costs less than seeing someone who is out of network. If you choose an out-of-network therapist, you may have to pay more or cover the full costs of your sessions. Check your plan’s benefits before scheduling so you know what to expect.
How Do I Check What My Plan Actually Covers?
Start with your Summary of Benefits and Coverage. Every plan has to provide one, along with a uniform glossary that defines terms such as deductible and copayment, and all insurance companies use the same standard form.
From there, log in to your member account or app and look at your plan’s benefit details, then call Member Services at the number on your ID card. Ask what you pay for an outpatient therapy visit in network, what you pay out of network, and whether anything requires prior authorization.
Ask the therapist’s office to verify your benefits before the first session as well. Whenever possible, ask for the details in writing so you can refer back to them if needed.
What Protections Do I Have Under Parity Law?
The Mental Health Parity and Addiction Equity Act requires most health plans and insurance companies that cover mental health or substance use conditions to make those benefits comparable to medical and surgical benefits.
In practice, the law reaches three kinds of limits, which generally cannot be more restrictive than the ones applied to medical care. These are:
- Financial limits, such as deductibles, copayments, coinsurance, and out-of-pocket maximums
- Treatment limits, such as caps on the number of visits or days covered
- Care management limits, such as requiring authorization before treatment begins
If something looks inconsistent with how your plan handles medical care, you can ask for the reason in writing. You can also appeal the decision process or file a complaint with your state insurance department.
How Do I Find a Therapist Who Takes Anthem?
Start in the plan’s provider search. Anthem points members to the Find Care feature on its member site or app to search by location or specialty, and notes that members with an Employee Assistance Program may have a set number of counseling visits each year at no cost.
Insurance coverage can help you access therapy, but finding a therapist you feel comfortable with is also an important part of the process. . Rapport and trust are essential, so treat the first call as a two-way conversation. Our guides to the types of therapists and to questions to ask a new therapist can help you narrow things down.
We created Mental Health Match to make the search part easier. You answer a few questions about what you are dealing with and what you want in a therapist, and we introduce you to therapists who fit. It is free to use, and insurance is one of the things you can tell us about. Confirm Anthem participation with the therapist’s office before your first appointment, since billing runs through the practice rather than through us.
| Disclaimer: This article is for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Coverage varies by state, plan, and employer and changes over time, so confirm your benefits directly with your plan. If you are in crisis, please call or text the 988 Suicide & Crisis Lifeline at 988. |
