Typically we need therapy when we are in pain, which means we are at a time in our lives when we are paying the least amount of attention to detail. It can feel like a “kick me when I’m down” situation if you are finally starting to see light at the end of the tunnel and your health insurance claim for your much-needed therapy is denied.
This is why we’ve prepared this at-a-glance guide to help you navigate your health insurance policy while you are also seeking or receiving physical or mental health therapy.
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First and foremost, you will need to pay a therapist out of pocket and then submit your claim to be reimbursed by your insurance company. Let there be no misunderstanding about that, and also note that therapy sessions are typically between $80 to $200 per session.
For the most part, your health insurance company will cover a large portion of this amount, but of course it depends on your insurer. For mental health-related therapy, the term you need to look for is behavioral therapy or behavioral health services.
Under the Affordable Care Act (ACA), state-run Medicaid covers mental health and substance abuse services, including addictions counseling.
Original Medicare covers the same under Plan A, but you may need to pay a deductible and/or coinsurance if you are hospitalized or need to stay in a medical facility.
Under Medicare Part B, outpatient mental health services are covered, such as assessments and screenings in a doctor’s office or community health care clinic. You may incur out-of-pocket costs for therapy sessions, such as deductible, copay, and coinsurance amounts. As with medical or surgical expenses, once you’ve reached the annual out-of-pocket maximum for an individual, Medicare will cover the rest.
If your health insurance is provided by your employer, whether or not therapy is covered depends on the size of your company! If your company has 50 or more employees, it might not be covered (but it almost always is). Providing health insurance to their employees is a legal requirement for large companies, but the health insurance plan does not legally need to cover behavioral health services.
If your health insurance is provided by your employer and your company has fewer than 50 employees, therapy is almost certainly covered. Under the Affordable Care Act (ACA), any plan purchased through the Health Insurance Marketplace must offer 10 essential health benefits, of which therapy is one.
According to the Act, even if you have a pre-existing condition, your insurer is required to cover these expenses and they cannot limit the dollar amount of coverage per year, if your combined deductible, copay, and coinsurance have reached your out-of-pocket maximum. Not all companies with fewer than 50 employees provide health insurance, as it is not mandatory for them to do so.
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All insurance plans require you to check beforehand whether or not your chosen counselor or therapist is a network provider, meaning they are registered to take insurance. Some even provide you with a list of network providers.
You can work with a therapist outside of this network, but you should first find out if you have “out of network” coverage. Typically health plans cover 60-80% of out-of-network provider fees, but you may have to pay copay amounts up-front to the therapist, and these fees can be high.
Even though personal wellness is an established benefit to families, companies and communities, many people simply do not claim their receipts for therapy or counseling. This is because insurance companies only pay for medically necessary services, which means they require a mental health diagnosis before they will pay claims. Most people are not comfortable with this, especially if their health insurance is provided through their employer.
These persistent stigmas have a huge impact on individual well-being and the health of entire families. The person suffering might even resist getting any kind of therapy altogether, which tends to worsen their condition.
We hope that if you feel you need therapy, you will receive the treatment you need and be fairly reimbursed. Nobody deserves to have financial set-backs in addition to the stress of going through a physical or psychological hardship.
Claire Smith Claire is a creative entrepreneur with a variety of marketing and content creation skills, including blog and web copy writing, research, and strategy. She has a Masters in Cultural Studies from Queen's University and is known for thinking laterally about marketing, based on her deep knowledge of people and behavior.
