What To Ask My Insurance Company So I Actually Understand How Much Therapy Will Cost
/How much will my insurance company reimburse me for therapy? This topic makes most people’s heads spin - for good reason! There is a lot to consider and it can be overwhelming. We made a list of questions to ask your insurance provider so you know the costs before you connect with a therapist.
Start by calling the member hotline on the back of your insurance card and ask the following questions:
Do I have in-network mental/behavioral health benefits?
If the answer is yes, you can see any provider that is in-network with your plan (e.g., if you have Aetna, you can see a provider who takes Aetna).
In-network is more affordable than out-of-network. This is because in-network providers have agreed to accept a discounted rate for services in exchange for being part of the insurance company’s network.
What is my in-network deductible?
Has any amount of my deductible been covered this year?
What is my copay amount?
You are usually responsible for paying a deductible for in-network services (usually $100-$2,000/year), and after that is met, you are responsible for covering only the copays (usually $10-$75/session). The therapists will be reimbursed the remaining balance directly by the insurance company.
Do I have out-of-network mental/behavioral health benefits?
If you can afford to pay more for your therapy and you have out-of-network coverage, you have access to MANY more therapists in NYC. With out-of-network benefits, you will pay more, but you can choose any licensed therapist you’d like to see and your insurance company will reimburse you for the costs. Out-of-network therapists in NYC charge between $100-$500/session.
A plan that includes out-of-network benefits is usually referred to as Preferred Provider Organization Plan (PPO) or Point-Of-Service Plan (POS).
Do I have an out-of-network deductible that has to be met first before I get reimbursed? Has any amount of my deductible been covered this year?
Out-of-network deductibles can range from $100-$10,000/year.
If any amount of your deductible has been met, you will only be responsible for meeting the remaining amount. For example, if your out-of-network deductible is $3,000 and you have already seen an out-of-network provider for $1,000 of services, you will only need to pay for $2,000 of therapy sessions before receiving reimbursement.
What is my co-insurance amount?
Co-insurance typically ranges between 20%-40% of the session cost. Co-insurance is the amount that you pay out of pocket - without reimbursement - per service after your deductible has been met.
For example, if the cost of the session is $200, you will be reimbursed between $120-$160/session by your insurance company.
What is the usual and customary rate covered by my insurance for outpatient psychotherapy (CPT code 90834)?
This is the million dollar question! Insurance companies do not reimburse just any old cost that your therapist charges. They will cover a X% amount of what they deem is acceptable for a therapy session in NYC - this is often referred to as “customary rate” or “allowable amount”. Each plan in each insurance company “allows” a different amount.
At Therapists of New York, we have seen allowed amounts range from $60-$250/session, with the average being $180/session. This means that if your co-insurance is 30%, your insurance company will reimburse you 70% of $180 (the allowed amount), even if your therapist charges $200/session. So let’s calculate:
You pay your $200 for a session.
You or your therapist send a bill to your insurance company.
Your insurance company decides that they will “allow” $180/session
Your co-insurance is 30% so your insurance company reimburses you 70% of $180 (= $126).
In a nutshell, you pay $200 and your insurance company sends you a check for their part, which is $126. Your out-of-network therapy will cost you $74/session. Not bad for high quality therapy from any provider you want to see in NYC!
If you want to learn more about insurance, check out our blog Simplifying the Baffling World of Health Insurance. If you have any questions about how much your insurance company will reimburse you for services with Therapists of New York, click here or email us at info@therapistsofny.com.