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.

Questions For Your Initial Therapy Consultation

You spend months thinking about starting therapy. The search for a therapist is time consuming and unsatisfying. There are false starts and missed connections. Finally, you find a therapist that can work. Reading their profile, you find thoughts and phrases you can relate to, and their approach to therapy speaks to you.

Now it’s time to reach out to the therapist.

EMAIL THE THERAPIST

Your time is precious. Therapists are busy. Email for both of you is the easiest way to communicate. Make sure to clearly address the following in your email:

• Scheduling - Let the therapist know what days and times are convenient for your weekly therapy appointment.

• Fees - Ask the therapist’s per session fee.

• Insurance - See if the therapists accepts your insurance.

• Location - Confirm the therapists location.

If one of these conditions is not going to work for you, then it’s best to move on. You can ask for a referral.

Otherwise, if you can make these 4 things work, ask to set up an initial consultation phone call.

YOUR CONSULTATION PHONE CALL

The following is not intended to be a script. These are just some guideposts to help you along the way. Every call with a therapist will go in a different direction. Many therapists will start off with some version of “So why are you calling? What’s been going on?” In every case, this is supposed to be a fluid introductory conversation. Expect the call to take no more than 15 minutes. Find a comfortable time and place, and don’t feel rushed.

CAN WE CONFIRM THE FOLLOWING?

When talking with the therapist on the phone, confirm the information in the email.

Scheduling - The date and time needs to work on a weekly basis. If not, try and find a weekly day and time that works for you both. If scheduling doesn’t work, then ask for a referral. Make sure you can consistently attend every week, and some therapists have a cancelation fee.

Fees - What does the therapist charge for a weekly session? What payment do they accept? Some therapists have a sliding scale depending on your financial situation. You should be open and transparent about your comfort with fees. Consider this to be a 12 week minimum commitment. Ask about the therapists cancelation policy.

Insurance - Most therapists will not deal with your insurance. They leave the whole headache up to you (We take care of this for you at Therapists of New York!). It is to your benefit to contact your insurance carrier to understand your benefits. For a complete guide to insurance. Click Here.

Location - Get clarity on the following: Address; nearest subway, bus, or parking lot.

TALK ABOUT WHY YOU ARE SEEKING THERAPY.

After the basics, it’s now time to talk about why you are calling. This is just a high level overview to describe feelings, recent experiences or troubling behavioral patterns. There’s no need to analyze details of your life. This is a big picture conversation. Where you can both determine if you click.

DO YOU HAVE ANY SPECIALIZATIONS?

Many therapists are generalists. They see all types of patients with various treatment goals. Yet many also have specialties or interests that they are extra suited to treat. These specialties may range from eating disorders, to addiction, to couples, to grief. Ask about specialties, especially if you have specific issues you want to work on in therapy.

DO YOU HAVE A STYLE?

Thankfully, therapy is not one size fits all. There are different styles of therapy which have grown out of theories of thoughts, emotions, and behavior. While some therapists can move between styles, most have a default where they are comfortable. Ask what their preferred style of therapy is, and how that looks in a session. Ask yourself if their style is what you have in mind, and if you think it will be helpful.

HOW DO YOU WORK?

There are many ways to answer this questions. They may focus on actionable goals or support or gaining a deeper understanding of yourself. Their response can help you to gauge if you are a good fit. Does their answer feel like they are aligned with your goals?

WHAT DO YOU THINK THE LENGTH OF TREATMENT WILL BE?

Therapy takes time. It’s not as simple as take 2 aspirin and call me in the morning. At the most basic level, you and your therapist need to do a little cerebral or behavioral rewiring. This takes time to be effective. Research shows that 26 sessions seems to be a sweet spot. Many people find that they like therapy as a safe place they can open up and talk, and choose to stay in therapy for years. It’s up to you and your therapist.

HOW LONG IS A SESSION?

Most therapy session run between 45 and 50 minutes. Couples or family sessions are usually 60 minutes. Confirm with your therapist.

SET UP YOUR WEEKLY APPOINTMENT

If you’re satisfied with the conversation, then set up an initial appointment. Get there a bit early sit back, breathe deeply, and relax. Allow the therapist to guide the session. If you feel awkward or uncomfortable during the session, let the therapist know so they have a chance to get it right. If it still feels off, move on to someone else. Trust your gut. It should feel right.

Simplifying the Baffling World of Health Insurance

In Network. Out of Network. Copays. Co-Insurance. Out of pocket. Reimbursement. Deductibles.

As therapists we have been doing this for years, and we still get tongue tied. Once you understand the concepts and definitions, you may find you can afford premium healthcare.

One of the biggest hurdles is understanding your mental health benefits. Not all health care plans are the same. Different plans allow for different coverage. Some plans do not cover mental health services, but most do. Before you start therapy, it is important that you understand the costs so that paying does not hinder your ability to attend regularly (keep that momentum going!). You can find information about your particular benefits by signing into your insurance carriers website, calling the member hotline (found on the back of your card), or contacting your HR Department. Click here for questions to ask.

You also need to verify if your mental health coverage includes out-of-network benefits, or if your coverage limited to only in-network coverage. If your plan does not cover mental health services, then you will need to pay for therapy out of pocket. If your health care plan allows for only in-network therapy, your therapist will need to accept your insurance or you can choose to pay out of pocket. Verify with your therapist if they are an in-network or out-of-network provider.

If your plan allows out-of-network mental health care, then you can see a therapist of your choice. In most cases, you will need to pay for the entire therapy session upfront and out-of-pocket. You will then be responsible for submitting an insurance claim to your insurance company for reimbursement. Generally speaking, you will only be reimbursed a portion of the total cost, anywhere between 25% and 80%. For example, if a session costs $200, you will pay your therapist $200, your therapist will send you an invoice, you will either mail the invoice to your insurance carrier or upload the invoice to your insurance carrier’s website. Finally, they will mail you a check for between $50-$160. It sounds complicated but once you do it once, it is relatively straightforward.

Let’s get into specifics.

Generally speaking, there are 3 types of insurance:

HMO (Health Maintenance Organizations) - Only provide in-network healthcare services. As part of an HMO, you need to designate a primary care physician (PCP). This physician is your gate keeper, and needs to approve you to go and see another healthcare service such as a therapist. This therapist must be in network to be covered by your insurance. This is the most restrictive type of health care plan.

EPO (Exclusive Provider Organizations) - Only provide in network healthcare services. With EPO you generally do not need a primary care physician (unless your plan in “gated“). You can seek out additional healthcare services on your own, such as a therapist. This therapist must be in-network to be covered by your insurance. This is less restrictive than HMO health care plans.

PPO (Preferred Provider Organizations) - Provide in-network and out-of-network health care coverage. Out-of-network coverage has a higher out of pocket cost, but PPO’s will cover some portion of it depending on your plan.

POS (Point of Service Plans) - You need to have a PCP, but they can refer you to out-of-network health services. Some portion of the expense may be paid by your insurance company, depending on your health care coverage.

Below is a list of all the terms to help you understand your healthcare benefits.

PREMIUM - The amount you pay the insurance company each month to have health insurance.

DEDUCTIBLE - The total amount of money you have to pay out of pocket before your insurance benefit starts. Typical deductibles are between $500 and $5000. So let’s imagine an in-network therapist charges $100 per session, and your deductible is $500. You would have to pay your therapist $100 for 5 sessions out of pocket, before your insurance company would begin to pay.

IN-NETWORK - This refers to therapists that are covered by your insurance plan. Insurance companies typically dictate the fee that therapists can charge their patients.

OUT-OF-NETWORK - This refers to therapists NOT covered by your insurance plan. Your insurance plan may still provide some coverage for out-of-network therapy.

COPAY - This is the amount of money that you owe every time you visit your in-network therapist. It is typically between $10 and $50 per visit.

OUT-OF-POCKET - The money that you need to pay directly to your provider.

REIMBURSEMENT - This is the money that your insurance company repays you after you pay your therapist in full. Typically this occurs for out-of-network therapists that do not take insurance. You pay the entire session fee yourself out-of-pocket, then submit an insurance claim to the insurance company to get reimbursed for the out-of-network treatment. This only works if the your insurance plan covers out-of-network therapy.

PCP (Primary Care Physician) - Doctors that act as the gate keepers to other health services. In the cases of plans where a PCP is required, you must have them “OK” you to see another healthcare professional.