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How Does Out-of-Network Coverage Work for Mental Health Services & Therapy?

How Does Out-of-Network Coverage Work for Mental Health Services & Therapy?

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What Does Out-of-Network Mean for Insurance?

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 or contract between the provider and the insurer to accept negotiated costs.1 A health plan’s network of providers and medical facilities with whom it has negotiated a discount is considered in-network.

Due to the high demand for therapy, some mental health therapists may only deal with a small number of insurers. This is due to the large number of patients who will pay out-of-pocket. In contrast to in-network therapy, out-of-network therapists can provide longer and more frequent therapy sessions. They can also provide out-of-the-box solutions and care plans.2

Furthermore, nearly one-third of therapists do not accept insurances of any kind. There are a variety of reasons why therapists could decide not to accept insurance coverage for mental health services, including the following:3

  • Low reimbursement rates
  • Dealing with insurance companies
  • Unbalanced supply and demand

How Does Out-of-Network Coverage Work for Therapy?

Do some research beforehand to determine how much you’ll be paying if you see an out-of-network therapist. It’s important to verify your insurance plan’s out-of-network benefits and whether or not your deductible applies to these services. In addition, you’ll want to know if your insurance company will require a referral, among other things.

Athena Care is in-network with most major insurance plans, which could save you money when you receive therapy or mental health services.. Filling out our free and confidential online insurance verification form is the best method to determine the specifics of your out-of-network therapy coverage. A care coordinator can assist you with any questions or concerns regarding out-of-network insurance for mental health Monday through Friday, 7:00 a.m. to 6:00 p.m., at one of our multiple mental health services offices in Tennessee.

Out-of-network therapy has a slightly different payment procedure. An out-of-network therapist gets paid immediately, but the patient has to wait to be reimbursed. In other words, the provider receives payment sooner since you pay the full amount up front. At the same time, you wait to receive reimbursement from insurance.

On occasion, therapy offices (typically group practices with designated billing departments) will submit insurance claims on your behalf. You’ll then receive a check from the insurance company. Other times, it will be up to you to request a refund. If that’s the case, your therapist will send you a “superbill,” which is essentially a comprehensive receipt that you can mail or submit online to your insurance company. Getting reimbursed for out-of-network therapy could take many months, depending on the insurance company.

The most significant hidden disadvantage of hiring an out-of-network provider is that your insurance won’t actually cover 50% of your payment. Instead, they pay 50% of what they deem a “reasonable and customary” fee for a professional with comparable credentials in that field.

It’s crucial to understand that what therapists charge differs from what an insurance company deems “reasonable and customary.” For example, in a big city where insurance companies say $70 per session is a “reasonable and customary” cost, it’s not unusual to see therapists charging $150. In this scenario, you’ll be responsible for paying that $150 fee upfront while waiting to be reimbursed $35 from the insurance company. As a result, your total out-of-pocket expense for one out-of-network therapy session is $115.

Finding a therapist who charges the amount your insurance provider considers “reasonable and customary” can be challenging.

Pros & Cons of Out-of-Network Mental Health Coverage

There are a variety of potential advantages and disadvantages when using out-of-network coverage for therapy and mental health services.

Potential pros when using out-of-network coverage may include:

  • No Waitlists: The chances of you getting an immediate appointment for out-of-network counseling are sometimes higher than going in-network. The supply of in-network therapists is limited.
  • Specialized Care: an out-of-network therapist has more freedom than an in-network provider. As a result, they can provide more personalized care, out-of-the-box treatment, longer and more frequent sessions, and more.
  • Privacy: Going out-of-network can provide levels of privacy not found with most in-network insurers, particularly if you pay for therapy without insurance. This means you don’t submit any information to your insurance company.
  • Communication & Accessibility: Patients frequently desire to communicate questions or concerns to their therapists between or before sessions. Numerous out-of-network providers provide their patients with phone, text, and video communication.
  • More Choices: Whether a patient’s new insurance plan goes out-of-network with their favorite therapist, or they are looking for a new one, they won’t be restricted to the in-network list of therapists that are stipulated by their insurance provider. Patients may continue to see their long-time therapist whether or not they are in-network with their insurance provider.

Potential cons when using out-of-network coverage may include:

  • Affordability: Staying in-network usually costs less out-of-pocket than seeking out-of-network services.
  • Quality/Consistency Standards: Insurance companies do a pretty upstanding job at quality control. Opting for out-of-network therapy doesn’t come with the same consistency and standards you’ll find in-network.
  • Surprise Balance Billing: If the insurance company doesn’t cover the expected amount or any amount, you are responsible for paying the balance. Out-of-network providers can bill you. In contrast, an in-network provider cannot balance bill a customer.
  • Additional services that need approval are not authorized in advance: You’ll be required to seek approval from your insurance company if you wish to be reimbursed for additional services.

Why Would You See an Out-of-Network Therapist?

Some insurance covers only a set number of services and sessions annually. Because they are dealing with a mental health professional not covered by their insurance, some people may choose not to work with an insurance provider. In addition, to provide a referral, a diagnosis is typically required. The insurance company then needs the diagnostic and referral authorization to issue a reimbursement.

The privacy issue is another reason you may wish to see an out-of-network therapist. Each session’s information is kept confidential; most of the time, billing and financial records are also. Furthermore, if you need to reach a deductible before the insurance coverage begins, you might be forced to pay out-of-pocket anyway.4

Below are a few additional reasons why you may want to consider seeking out-of-network therapy:

  • High Deductible: If your deductible is $6,000 and you have not yet incurred any other medical costs for the year, you’re responsible for paying the total cost of your treatment sessions up to $6,000 before your copay kicks in. In this instance, the cost of attending in-network therapy and out-of-network therapy may be almost equal.
  • Great Out-Of-Network Benefits:5 Your insurance provider may reimburse up to 90% of session fees if you have substantial out-of-network benefits. This means that, in some cases, using your out-of-network benefits may be less expensive than or on par with your typical copay to see an in-network therapist. In some cases, patients must pay their in-network therapist the first $5,000 of care in advance. After meeting the $5,000 deductible, patients are informed that they have reached the maximum number of in-network sessions that the insurance provider would cover. In other words, the patient paid out of pocket for the in-network service and received no insurance benefit. The same patient would have received 80% to 90% of the expenses refunded had they used their out-of-network benefit!
  • Wait Time: The few therapists that are in-network frequently have enormous wait lists and are solidly booked. Private pay, out-of-network therapy may provide more availability and flexibility when scheduling new patients.
  • Continue to See the Same Therapist: Sometimes a patient’s insurance plan may change, or they may change insurance providers due to a new job. A patient may wish to continue to see a therapist that is now out-of-network that they have already been seeing for a long time and that they already trust.  

What Types of Mental Health Services Can Out-of-Network Insurance Cover?

Depending on the details of your particular plan, out-of-network insurance benefits may cover the following:

  • Treatment for behavioral and mental health, such as counseling and psychotherapy
    • Outpatient therapy, including Transcranial Magnetic Stimulation (TMS), Spravato, and Eye Movement Desensitization and Reprocessing (EMDR)
  • Inpatient care for behavioral and mental health
  • Treatment for substance addiction and substance use disorders
    • Rehab, Cognitive Behavioral Therapy, etc.
  • Medication Management

Benefit amounts and limits vary depending on your location and your chosen plan. Also, remember that not all services are necessarily covered just because insurance pays for mental health tests and treatments. For instance, alternative therapies like acupuncture might not be covered.6

How Much Can Therapy 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 final cost of treatment or what you may pay in Tennessee.

You’ll most likely be responsible for paying a portion or all of your medical expenses until the deductible is met. After that, you could have to pay a copay or coinsurance for services or treatments, depending on your insurance plan.

The cost of a single therapy session in the United States typically ranges between $100 and $200. Still, many providers may charge less, while others will demand more. Whether a client has health insurance affects the final cost, of course.7

Some licensed mental health therapists will offer a sliding scale if a patient doesn’t have insurance or if the therapist doesn’t 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 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. In addition, payment plans and the following alternatives may help you afford and receive mental health services, like therapy:8

  • 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.

Sources

  1. Anderson, Steve. “What Does Out of Network Mean?” healthinsurance.org, 7 July 2022, www.healthinsurance.org/glossary/out-of-network-out-of-plan.
  2. 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-.
  3. 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.
  4. BetterHelp Editorial Team. Choosing an Out of Network Therapist: Options Available Outside Your Plan | BetterHelp. 29 Dec. 2022, www.betterhelp.com/advice/therapy/what-you-need-to-know-when-choosing-an-out-of-network-therapist.
  5. “Reasons Why Out-of-Network Services Are Better.” Ayre Counseling, 2023, ayrecounseling.com/reasons-why-out-of-network-services-are-better.
  6. 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
  7. Psychology Today Staff. “Cost and Insurance Coverage.” Psychology Today, 2023, www.psychologytoday.com/us/basics/therapy/cost-and-insurance-coverage.
  8. 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. 

(615) 320-1155