A Guide to Navigating Insurance: Therapy

Premiums: 

You pay a regular amount (monthly or annually) to the insurance company

Policies: 

The insurance company gives you a contract, called a policy, that explains what is covered. For example a health insurance policy, also known as a health plan, is a package of health care services and items that a plan covers, how much it will pay for them, and for how long.

Claims: 

If you get medical treatment, you or your doctor send a request (claim) to the insurance company to pay for it.  Medical providers and therapists use CPT codes on the claim they send in to describe the services they provided. 

Deductibles: 

You pay a certain amount of your medical costs before the insurance starts to pay. For example, if you have a health insurance policy with a $500 deductible and you receive a medical bill for $1,000, you would be responsible for paying the first $500 and your insurance would cover the remaining $500.  A deductible policy also stipulates that you would pay a percentage before the deductible is met or a percentage even after it’s met. So, with a policy with a $500 deductible that pays 80% after deductible is met, you still would be responsible for 20% of all charges after the deductible is met. 

Copayments:

You pay a fixed cost for doctor’s visits and services (e.g., $20 for a doctor visit), 

Coinsurance: 

You pay a percentage of the cost (you would pay 30% of each medical bill, and your health insurance will cover 70%). 

Private Insurance Companies: 

These companies sell health insurance plans. Examples include UnitedHealthcare, Blue Cross Blue Shield, Aetna, and Cigna. The healthcare.gov website, sometimes called the Health Insurance Marketplace or Obamacare offers a range of plans, making it easier to find coverage that includes mental health services.

Employer-Sponsored Insurance:

Many employers offer health insurance as part of your job

Government Programs: 

Programs like Medicare (for people 65+ or with certain disabilities), Medicaid (for low-income individuals), and CHIP (for children)

Health Insurance networks are groups of doctors and hospitals that work with your insurance company. The two main types are: 

Preferred Provider Organization (PPO): 

Offers flexibility in choosing doctors and hospitals. You can see specialists without a referral and get some coverage for out-of-network providers

Health Maintenance Organizations (HMO): 

Requires you to choose a primary care provider (doctor) and get referrals to see specialists. Coverage is usually limited to in-network providers, but costs are often lower.

Evaluate Your Needs: 

Think about your health, age, and any existing conditions.

Compare Plans: 

Look at different policies, comparing premiums, deductibles, and coverage.

Check the Network: 

Make sure your favorite doctors and hospitals are included in your policy before making final decisions. Search by the provider’s name and NPI number if possible. You can obtain the NPI number by asking the provider for it or searching for it here. 

Understanding the Policy: 

Read what is covered and what is not.

In-network providers

Imagine you're picking a video streaming service. Each plan comes with different shows and movies right? For example if you want to watch Frozen, which is a Disney movie, you would choose Disney Plus. Or, if you wanted to watch Stranger Things, you would choose Netflix. It's like that with insurance. Depending on which plan you choose, certain doctors are included.   So, before you sign up, it's like checking the lineup: you have to contact the service and ask if your favorite show (i.e., doctor) is on the plan you're considering. 

Carve outs

What are carve outs? A carve-out happens when a specific benefit service CPT codes) is excluded from a plan’s coverage. This is typically done to reduce costs and boost revenue for an insurance company. For instance, an insurance company might separate pharmacy benefits from medical benefits, or an HMO Plan might exclude mental health benefits. Or, an insurance company may carve out these services to another company that doesn’t include the provider you want to see on their panel. As a result, you are not covered for these services and would have to pay the full service price. This is why it’s important to check if the services you use, or think you may need to use, are actually covered by your policy or they’re carved out to a different company.  

Medical necessity 

 Therapy is typically considered a medical expense as long as there is medical necessity, that is the therapist has to provide a diagnosis. Without a diagnosis, insurance will not reimburse for mental health services. An example of this is couples therapy. Many therapists don’t provide a diagnosis for couples therapy as the therapist is seeing a couple and treating a relationship, not an individual. Therefore the service would not meet the medical necessity criteria and would not be covered by insurance.

Services not being covered

Some insurance plans do not cover certain services (e.g., family therapy, couple’s therapy). It’s important to call the number on the back of your card and ask what services are covered. You can also ask the therapist what CPT codes they will be submitting on their claims to see if those codes are covered. 

Conclusion

Health Insurance is important for staying physically and mentally healthy and avoiding high medical bills. Whether you're young or old, having insurance helps you get the care you need without breaking the bank. By understanding how insurance works and choosing the right plan, you can protect your health and your wallet.