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What Does In-Network Mean for Insurance?
A health plan’s network of providers and medical facilities with whom it has negotiated a discount is considered in-network. Because these networks have agreements with insurance companies to deliver services at cheaper costs, insured individuals typically pay less when using an in-network therapist or provider.
Following the terms of their contract, the provider must take the insurer’s payment (plus any cost-sharing from the patient, such as the deductible, copay, or coinsurance) as full payment. An in-network provider is not permitted to balance bill a customer.
Other insurance plans will pay at least a portion of the claim even if a member uses an out-of-network physician, in contrast to some health insurance plans that only pay for treatments when a member uses in-network physicians.1
Out-of-network is typically used to describe doctors, hospitals, or other healthcare providers who are not a part of an insurance network. This indicates that there is no written agreement between the provider and the insurer to accept the negotiated costs.2
Although they are less prevalent than they once were, plans that cover out-of-network treatment are still available. However, when consumers receive mental health services or care from an out-of-network provider, they typically impose a higher deductible and out-of-pocket maximum (or perhaps no limit).
Nearly one-third of therapists do not accept insurances. There are a variety of reasons why therapists could decide not to accept insurances, including the following:3
- Low reimbursement rates
- Dealing with insurance companies
- Unbalanced supply and demand
In contrast to in-network therapy, out-of-network therapists can provide longer and more frequent sessions. They can also provide out-of-the-box solutions and care plans. Furthermore, except for emergency or urgent care, services from a provider who is not a network member are regarded as out-of-network. For an emergency room visit to be considered in-network, the reason for your visit must constitute an emergency.4
How Does In-Network Coverage Work for Therapy?
To be considered in-network therapy, the therapist is listed in your insurance provider’s database or has submitted an application and been “authorized” by your provider. Session fees will likely include a “copay,” due when you arrive for your appointment.
A copay may cost $15 to $85 (sometimes even more or less). The remainder of what your insurance company determines to be a reasonable amount for the in-network counseling will be paid to your therapist. For example, you pay your therapist $50 at the beginning of each session if the insurance company values a session at $100 and your copay is $50. After the therapist submits the paperwork, the in-network insurance for mental health would then be responsible for paying the remaining $50 to the therapist.
When looking for an in-network therapist, typically your insurance provider has a list of in-network therapists for you to choose from. You may also confirm with your therapist of choice whether your insurance is in-network.
Athena Care providers are in-network with many big-name providers like Blue Cross Blue Shield, Aetna, TRICARE and more. Fill in our insurance verification form below to see if you qualify.
Pros & Cons of In-Network Mental Health Coverage
There are advantages and disadvantages in certain situations for using in-network insurance coverage for therapy and mental health services.
Potential pros may include:
- Affordability: After meeting your deductible, you only have to pay a nominal copay for each session.
- Quality/Consistency Standards: You can be confident that you’re getting the best care possible because providers are held to strict quality standards for plan members.
- Payment for preventive services may be 100%: The insurance providers pay the full amount for preventive services.
- Services that need approval are authorized in advance: In-network providers will seek prior authorization for additional services (i.e., x-ray, CT scan, etc.). The member will not be required to do anything but wait for approval.5
Potential cons with in-network insurance may include:
- Waitlists: Many in-network therapists will have long waiting periods.
- Supply/Demand: There are increasingly fewer therapists who accept insurance. The ones that do are usually fully booked.
- Ever-changing Rules/Regulations: Contracting with payers is not always a walk in the park. Every payer has a set of guidelines for billing and/or treatment that can restrict a provider’s freedom.
- Limited Number of Sessions and “medical necessity” Requirement: The number of sessions you are permitted can be restricted by insurance providers. In addition, for example, those with Major Depressive Disorder (MDD) may be eligible for insurance coverage. At the same time, those with mild depression who don’t fulfill the criteria for the diagnosis of MDD may not be covered.
What Types of Mental Health Services Can In-Network Insurance Cover?
Considering that mental and behavioral health services are deemed essential health benefits, every in-network insurance plan should provide some level of coverage for the following:
- Treatment for behavioral and mental health, such as counseling and psychotherapy
- Outpatient mental health treatments, including ABA therapy and Spravato
- Inpatient care for behavioral and mental health
- Treatment for substance addiction and substance use disorders
- Rehab, Cognitive Behavioral Therapy, etc.
The Mental Health Parity and Addiction Equity Act (MHPAEA) doesn’t mandate that health plans include insurance benefits for mental health or addiction. But if they do, treatment caps and out-of-pocket expenses must be on par with those for medical and surgical care.6 The MHPAEA applies to Medicaid-managed care plans, large group, and self-insured health plans.7
Benefit amounts and limits vary depending on your location in Tennessee and your chosen plan. Also, remember that not all services are necessarily covered just because a plan pays for mental health tests and treatments. For instance, financial problems or stress brought on by life upheavals like divorce might not be covered. However, stress as a sign of a medical condition such as depression is usually covered.8
How Much Do Mental Health Services & Testing Cost?
Mental health insurance coverage costs can vary depending on your specific health plan and personalized needs. The following are average costs, though they may vary by location and other factors. Therefore, these costs may not reflect the actual cost of treatment or what you may actually pay.
You will normally have to pay some or all of your medical expenditures until your total medical expenses reach the deductible. Then, depending on your plan, you may be required to pay a copay or coinsurance for each service or treatment.
In the United States, the typical cost of in-network therapy ranges from $100 to $200 a session.9 After meeting your deductible, you’ll most likely be responsible for paying a copay ranging from a few dollars to $50 or more a session.
Cognitive Behavioral Therapy (CBT) session fees are typically between $100 and $200 per session and are 45+ minutes long. Additionally, weekly individual therapy sessions, weekly group therapy sessions, and phone calls are the norm for Dialectical Behavior Therapy (DBT). Therefore, DBT costs vary depending on the duration and type of services rendered. Other factors, like whether the therapist is in-network or out-of-network, can influence what you pay out of pocket.
Some licensed mental health therapists will offer a sliding scale if a patient does not have insurance or if the therapist does not accept insurance. Suppose you find a therapist who will offer a sliding scale. In that case, your income will be considered when determining session fees. Additionally, this sliding scale may differ from one therapist to another.
Therapy cost without insurance can be intimidating. However, you should never put off getting critical behavioral and mental health attention because you don’t have coverage or don’t understand it. Calling the number of one of our multiple Tennessee-based mental health treatment centers is a great first step in determining your options for therapy services. A care coordinator will be ready and willing to help you Monday through Friday, 7 am – 6 pm.
In addition, payment plans and the following alternatives may help you gain access to and afford mental health services, like therapy:10
- Local social services: Free or low-cost mental health services may be available at student health centers or federally designated health centers such as community-based facilities sponsored by the federal government.
- University hospitals: Patients can often access interns and residents at university hospitals on a sliding fee basis. This is usually significantly less expensive than private practice mental health specialists.
- Non-profit options: Not-for-profit groups match inexpensive mental health treatments to middle and lower-income persons and their families.
- Employee Assistance Programs (EAP): Some employers pay for these benefits, providing employees free access. The employee handbook or human resources department can provide additional information on EAP benefits.
- Disability Benefits: If you have a persistent or severe mental condition that prevents you from working, you may be eligible for disability benefits. These advantages do not always include medical coverage. They may, however, be able to assist you in obtaining Medicare coverage, including mental health benefits, even if you are not 65 years old.
- Anderson, Steve. “What Does In-network Mean?” healthinsurance.org, 29 Aug. 2022, www.healthinsurance.org/glossary/in-network.
- Anderson, Steve. “What Does Out of Network Mean?” healthinsurance.org, 7 July 2022, www.healthinsurance.org/glossary/out-of-network-out-of-plan.
- Writers, Staff. “Therapists Who Don’T Accept Insurance | Psychology.org.” Psychology.org | Psychology’s Comprehensive Online Resource, 18 Aug. 2022, www.psychology.org/resources/therapists-who-dont-accept-insurance.
- Kennelly, Ryan. “Can I Use My Health Insurance Plan Outside of My State?” iHealthAgents, Jan. 2023, help.ihealthagents.com/hc/en-us/articles/224360547-Can-I-Use-My-Health-Insurance-Plan-Outside-of-My-State-.
- IU Human Resources. “In-network and Out-of-Network | Benefits | University Human Resources | Indiana University.” Indiana University, Jan. 2023, hr.iu.edu/benefits/networks.html.
- “1 Fairness in Mental Health and Substance Use Insurance Coverage.” TN.gov, Dec. 2021, www.tn.gov/content/dam/tn/health/program-areas/vipp/Parity-Fairness-in-Health-Coverage-Toolkit-2021.pdf.
- The Mental Health Parity and Addiction Equity Act (MHPAEA) | CMS. www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.
- Grey, Gina-Roberts. “Are Mental Health Services and Therapy Covered by Health Insurance?” GoodRx, Inc., 2022, https://www.goodrx.com/insurance/health-insurance/mental-health-insurance-how-to-get-help
- Lauretta, Ashley. “How Much Does Therapy Cost?” edited by Alena Hall, Forbes Health, 2021, https://www.forbes.com/health/mind/how-much-does-therapy-cost/
- Roberts-Grey, Gina. “How to Access Therapy and Other Mental Health Services If You Don’t Have Insurance.” GoodRx, Inc., 2022, https://www.goodrx.com/well-being/healthy-mind/therapy-mental-health-services-without-insurance
If you suspect that you or someone you love suffers from mental health disorders, contact Athena Care today.
One of our friendly associates will help you get the help you need. Take this first step to feel better and take control.