Find Therapy Covered By Insurance

Understanding key insurance terms will help simplify the process:

Insurance & Coverage Types

Health Maintenance Organization (HMO): A plan with lower premiums and out-of-pocket costs, but requires you to use in-network providers. Often requires selecting a Primary Care Physician (PCP) and referrals for specialty care. Services outside the network are typically not covered unless in emergencies.

Preferred Provider Organization (PPO): A more flexible plan that allows you to see both in- and out-of-network providers without referrals. Monthly premiums and deductibles are usually higher.

Exclusive Provider Organization (EPO): Like an HMO, but typically doesn’t require referrals to see specialists. Care is only covered if you use in-network providers (except emergencies).

Point-of-Service (POS): A hybrid plan requiring referrals from a PCP for specialty care, but offering some coverage for out-of-network care—usually at a higher cost.

High-Deductible Health Plan / Health Savings Account (HDHP / HSA): A plan with lower monthly premiums and higher deductibles. Often paired with a Health Savings Account (HSA), which lets you use pre-tax dollars for medical expenses like copays, coinsurance, and dental care.

Catastrophic Health Insurance: Low-cost, high-deductible plans for people under 30 or with a hardship exemption. Primarily designed to protect against worst-case scenarios.

COBRA: A law allowing you to temporarily continue employer-sponsored insurance after job loss—typically at full cost to you.

Marketplace Subsidies (ACA Plans): Income-based discounts on monthly premiums and out-of-pocket costs available through the federal or state health insurance marketplaces.

Payment & Cost Terms

Premium: The monthly fee you pay for health insurance.

Deductible: The amount you pay out-of-pocket for services before insurance begins covering costs.

Copay: A fixed fee you pay at the time of a medical visit, often varying by service type.

Coinsurance: A percentage of the service cost you pay after meeting your deductible.

Out-of-Pocket Maximum: The most you’ll pay in a year for covered care. After reaching this, your insurance pays 100% of covered services.

Sliding Scale: A fee model where rates are adjusted based on your income, often used by community clinics and mental health providers.

Fee-for-Service: A model where each service is billed separately. May involve paying upfront and submitting claims for reimbursement.

Paying Out-of-Pocket: When you pay the full cost of care directly without insurance or assistance.

Provider Types

In-Network Provider: A provider contracted with your insurance company. You’ll usually pay less to see them.

Out-of-Network Provider: A provider not contracted with your insurer. May result in higher costs or no coverage at all, depending on your plan.

Access & Assistance Programs

Charity Care Programs: Hospital or health system-run programs offering free or reduced-cost care for uninsured or underinsured individuals based on financial need.

Local Assistance Programs: Programs funded by state or local governments that help individuals who cannot afford healthcare services.

Grants from Nonprofit and Government Agencies: Funding provided to support access to mental health services for qualifying individuals. Includes local nonprofits and federal agencies like SAMHSA.

Federally Qualified Health Centers (FQHCs): Community-based clinics offering sliding-scale services, including mental health, regardless of insurance or income.

Community Mental Health Centers (CMHCs): Publicly funded clinics offering therapy, psychiatry, and case management to underserved populations.

Certified Community Behavioral Health Clinics (CCBHCs): Comprehensive care clinics for mental health and substance use that provide expanded services regardless of a person’s ability to pay.

State Welfare or Child and Family Services Funds: Funding and services for families and children needing support, often including mental health care. Learn more at childwelfare.gov.

CHIP (Children’s Health Insurance Program): Covers children in families with incomes too high for Medicaid but who can’t afford private insurance. Often includes mental health services.

Medicaid Managed Care: State-administered insurance plans provided through private insurers. Most Medicaid beneficiaries are enrolled in these and must identify which insurer manages their benefits.

U.S. Department of Veterans Affairs (VA) Funds: Health coverage and mental health services for U.S. veterans, including in-person, telehealth, and online resources. Learn more: mentalhealth.va.gov.

Indian Health Service / Tribal / Urban (I/T/U) Funds: Federal and tribal programs offering health and behavioral services to American Indian and Alaska Native communities.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): A Medicaid benefit for individuals under 21 that includes behavioral health screenings and services.

Step 1: Verify Your Therapy Coverage

Before you start looking for therapy covered by your insurance, make sure you have a clear understanding of your mental health care benefits as this can vary greatly depending on your insurer and specific policy.

How to check your coverage:

• Call customer service: Dial the number listed on the back of your insurance card, typically marked as "Behavioral Health Services" or "Member Services." You can say, “I'd like information on my mental health benefits and the costs associated with therapy sessions.”

Important questions to ask:

• Does my plan cover mental health or behavioral health services? (This may be listed under "behavioral health" or "mental health" benefits.)
• Does my plan cover both therapy and psychiatric care? (Some plans separate benefits for talk therapy vs. medication management.)
• Which types of providers are covered? (E.g., psychologists, licensed clinical social workers, marriage and family therapists, psychiatrists, psychiatric nurse practitioners.)
• Are both in-network and out-of-network providers covered? (If yes, what is the difference in reimbursement or copay/coinsurance rates?)
• Do I need a referral from my primary care physician (PCP)?
• Is prior authorization required before starting therapy or psychiatry? (Ask for a list of services that require preauthorization.)
• What is my deductible for mental health services? (Has it been met yet?)
• What is my copay or coinsurance for each visit?
• Are there separate costs for therapy vs. psychiatry?
• Are there tiered costs for different types of medications (e.g., generic vs. brand-name)?
• What pharmacy benefits does my plan offer for psychiatric prescriptions?
• How many therapy or psychiatry sessions are covered per year? (Some plans have session limits; others offer unlimited coverage.)
• Is continued approval required after a certain number of sessions?
• Are there diagnosis-based restrictions on coverage?
• Are there different coverage rules for telehealth vs. in-person visits?
• What’s the difference in coverage for inpatient vs. outpatient mental health services?
• If I need inpatient treatment, how many days are covered per year?

Additional tips:

• Customer support availability can vary; some insurance companies provide 24/7 support, while others operate during regular business hours.
• You can also typically find detailed information by logging into your online member portal and navigating to the mental or behavioral health section.

Step 2: Find a Therapist Covered by Your Insurance

Once you confirm coverage, find therapists covered by your insurance:

Where to look:

• Your insurer’s online provider directory for in-network therapists
• Specialized platforms like MiResource, which match therapists to your needs and help you find a therapist by insurance

Steps to confirm coverage:

• Verify directly with the therapist's office that they are in-network with your specific plan.
• Ask if they’re currently accepting new clients.
• Confirm whether they can verify your insurance benefits before scheduling your first appointment.

Step 3: Understand Referrals and Authorizations

Certain plans require additional steps before starting therapy:

• Referral from your primary care provider (PCP)
• Prior authorization from your insurance

Not completing these steps can lead to denied claims. Always clarify with both your provider and insurance what documentation is necessary.

Step 4: Clarify Session Limits and Covered Therapies

Insurance plans differ regarding therapy session coverage. Ask specifically:

• Are there limits on the number of sessions per year?
• Is couples or family therapy included?
• Is teletherapy covered like in-person therapy?
• Are specific therapy types (e.g., EMDR, CBT) covered?

Knowing these details upfront prevents unexpected costs.

Step 5: How Therapy Claims Work

Billing methods depend on whether your therapist is in-network or out-of-network:

• In-network providers typically bill your insurance directly. You pay only your copay or coinsurance.
• Out-of-network providers often require upfront payment, providing you with a "superbill" (itemized receipt) to submit to your insurer for partial reimbursement.

For out-of-network therapists, ask:

• Can you provide superbills?
• What's the typical reimbursement rate for my insurance?

Step 6: Estimate Your Costs

Before your first session, understand your potential out-of-pocket expenses:

• Deductible: Confirm if it has been met for the year.
• Copay or Coinsurance: Clarify whether it’s a flat fee or percentage-based.
• Check any session coverage limits.

Example:

If your plan has a $1,000 deductible, 20% coinsurance, and a $30 copay per session, a $150 therapy session would initially cost you the full $150 until the deductible is met. Afterwards, you'd only pay $30 per session.

Step 7: Know Your Mental Health Rights

U.S. federal law requires insurance plans to provide equal coverage for mental health services as for physical health (mental health parity). Your plan cannot:

• Charge higher copays for therapy than medical visits.
• Set more restrictive limits on mental health services compared to physical health services.

If you believe your plan is violating parity laws, you can file an appeal or complaint through your state's insurance regulatory agency.

Step 8: Using an HSA or FSA for Therapy

If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), these accounts can help you pay for therapy with pre-tax dollars, significantly reducing your costs. HSAs and FSAs can be especially useful if you have high deductibles or use out-of-network therapists.

Step 9: Addressing Denied Claims and Reimbursements

Occasionally, claims may be denied. Here's how to address such issues:

• Call your insurer immediately to find out why the claim was denied.
• Confirm billing details and diagnosis codes with your therapist.
• File an appeal promptly if you believe there's an error.

Appeals are common and often successful, so stay organized, document everything, and persist in resolving your issue.