I really just want to start this post about health insurance off by saying that insurance is sooooo complicated. So, just know that it’s confusing. Majorly confusing. One of the most confusing things about insurance is that each plan, even from the same insurance company, can be very different. So if I have two clients with BCBS insurance, their “patient responsibility” (what they owe) may not be the same. Here is some general information about types of plans.

If you have a community health plan (Medicaid/Medicare), services are typically covered 100% for you. Medicaid/Medicare is more likely to require pre-authorization, though it varies between companies. They are also more likely to limit the number of therapy sessions they will cover in a calendar year or 12-month period.

For private insurance plans (plans purchased through Marketplace or through your/your spouse’s employer), there are 3 types of plans I’ve seen:

• HIGH DEDUCTIBLE PLAN: This type of plan means that you, the patient, owe 100% of service costs before you hit your deductible. If your individual deductible is $2,500, your insurance plan will not pay out until you meet that deductible. You will be sent a bill for any charges. Once you met your deductible, your insurance may cover 100% of charges, or they may cover a certain percentage and leave you with the rest. I personally had a high deductible plan where I still owed 20% after meeting my deductible. However, you may see that your bill drops due to the difference in what your provider charges and the insurance plans “contractual rate.” I may charge a $115 fee per session, but if my contracted rate with an insurance company is $95, the insurance company will drop your bill down to $95.
• COPAY PLAN: This means that you will owe a set amount per visit, and your insurance company will pay the rest. Most of the clients I’ve seen with copay plans owe $20-$30 per session, but it can be a lower or higher amount. Check your copay amount for mental health – some insurance companies may consider therapists/counselors “specialists,” and some insurance companies charge a higher copay for “specialist visits.”
• COINSURANCE PLAN: I don’t come across these plans as much, but coinsurance plans exist, and with these types of plans, the patient will owe a certain percentage of all medical charges. The percentage varies between plans.

When I have a new client starting, I always recommend that they call their insurance company, if they haven’t already, to verify some information, including:

• That I, the provider, am in-network for their plan.
• That behavioral/mental health (outpatient) is covered under their plan.
• IF behavioral/mental health is covered, is there a limit on sessions per year.
• If telehealth is covered for outpatient mental health.
• What their patient responsibility may be (see note below).
• If authorization is required.

Your insurance company will give out information regarding your plan – if it’s a deductible, copay, or coinsurance plan. If it’s a deductible plan they will also tell you how much of your deductible has been met, and how much is left.

Your insurance company may or may not tell you what to expect, as far as cost. My cost per session varies significantly between insurance. Some pay out around $70 per session, some are a little over $100. I do not decide this cost – each insurance company decides what their contractual amount is. Also, your first session will be a slightly higher rate, as insurances pay out more for the initial assessment.

For Employee Assistance Programs (EAP), charges are typically covered 100%, BUT authorization is needed, and they only allow a certain number of sessions and those sessions must be completed in a specific amount of time (usually 6 months). Once you have completed the number of sessions authorized, you can call and ask for more (in my experience it’s hard to get additional sessions approved). You can also switch over and start using your regular insurance plan.

I hope that answers some questions and clears some things up. I’m happy to answer questions for my clients, and sometimes I end up calling insurance companies as well. While I try to be helpful, ultimately it is the client’s responsibility to verify insurance coverage.

When will you pay? Company policies vary, but for the company I contract with, copays and cash rates are due at the time of session. For coinsurance or deductible plans, we will not send you a bill until we receive an Explanation of Benefits (EOB) from your insurance (you should receive one from them as well). The EOB lets us know what charges your insurance allows, how much they cover, and how much the patient owes. At that time, we’ll send you a bill.

How do you reach out to your insurance company? There should be a “member services” number on the back of your insurance card, or one listed on your website. Some insurance plans have a website you can register an account with, then log in to view your coverage.

If you think of other questions you think should be included in this post, ask away in the comments!

Disclaimer: I am a licensed independent mental health practitioner and certified professional counselor, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a the