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Navigating the Insurance Maze: Things You Need to Know About Insurance Before Starting Therapy

Health insurance can be an incredibly confusing thing to navigate, especially if you’re thinking about starting therapy.

Whether you’re under a lot of stress, have symptoms of depression or anxiety, or are just unfamiliar with how to get coverage for therapy, we have all the information you need to get started.

Important Terms About Health Insurance

There are several different terms that people use when talking about health insurance coverage, and you might find yourself wondering what all of these terms mean. What is an insurance deductible? What’s the difference between a copay vs coinsurance? What about in-network vs. out-of-network care? What is coinsurance meaning in a healthcare plan?

Below, we’ve compiled some helpful terms and definitions that will hopefully clear things up for you.

  • Insurance deductible: The amount that you pay out-of-pocket each year before your health insurance coverage “kicks in” and your insurance provider begins paying for your healthcare.

  • Premium: The amount that you pay out-of-pocket for your health insurance coverage. If your insurance is provided through your employer, your premium might be deducted from your paycheck each pay period.

  • Copay: A set amount of money that you pay for specific services and prescriptions. A copay might be $25 for each primary care doctor’s visit and $35 for each specialist visit.

  • Coinsurance: Meaning a percentage of costs that you pay for medical services after your deductible has been reached.

  • Out-of-pocket maximum: The maximum amount of money that you will pay for healthcare costs that aren’t covered by insurance. Once you reach this maximum, your insurance should cover 100% of the cost of services.

  • In-network: Doctors, specialists, and medical centers that your healthcare plan has negotiated a special rate. In-network providers will be covered by your plan at a more affordable rate.

  • Out-of-network: Providers who are not in-network with your insurance provider. Using these providers usually incurs a higher cost.

Does Health Insurance Cover Therapy?

Yes, many health insurance plans provide coverage for therapy or counseling, but there are a few important things to note.

Many employers who provide insurance to their employees include coverage for mental health services. By federal law, companies that employ 50 or more full-time employees are legally required to provide insurance to employees, and most of those plans include some kind of mental health coverage. Medicaid and Medicare also include some coverage for mental health services.

Health insurance covers treatments that are deemed “medically necessary” in order to treat a specific condition. For example, a therapist or counselor might file a claim for Cognitive-Behavioral Therapy (CBT) on behalf of a client with an anxiety disorder. If the client has insurance coverage for mental health conditions, then insurance should cover treatment with CBT, as it’s an evidence-based treatment for anxiety disorders.

In order to submit claims to your insurance company, your therapist will have to make a diagnosis of some kind. Possible diagnoses could include things like acute stress disorder, adjustment disorder, or depression.

Some people feel uncomfortable with their insurance company having a record of their diagnosis, and may choose instead to self-pay for therapy rather than going through insurance.

Does Health Insurance Cover Therapy for Couples?

Many people wonder whether insurance can be used to pay for couple’s therapy or couple’s counseling. The answer is - yes, depending on the specific plan. Some healthcare plans do cover couple’s counseling, though the number of sessions may be limited to a set amount.

If you’re interested in couple’s therapy but aren’t sure if your insurance covers it, consider using some of the strategies in the section below to learn more about your coverage options.

How to Find Out If Your Insurance Covers Therapy

If you feel ready to start therapy, you might also feel unsure where to start with the insurance side of things. Thankfully, there are a few relatively simple ways that you can find out if your insurance covers therapy. Here are some ideas:

Review plan documents

Most insurance plans have written out plan documentation that details what’s covered and what isn’t, including information about the insurance deductible for that service, any copays, and coinsurance. This is usually called an Explanation of Benefits.

If you didn’t get a paper copy of these documents when you signed up for your insurance, you might be able to find a copy online. Try looking on the insurance provider’s website or your employer’s website, if your health insurance is through your employer.

Another place to look for coverage information is in the online portal provided by your health insurance. Most health insurance companies have a system online where you can log in and see information about your healthcare coverage. You may also be able to search for in-network providers through that system.

Call your insurance provider

If you have questions about what’s covered by your insurance, sometimes the best thing to do is to call your insurance provider and ask.

Yes, you might have to wait on hold for a little while, but calling your insurance can be the best way to get information about your coverage that isn’t available online. You may also be able to ask questions about specific scenarios and requirements of your plan - such as, does your plan cover couple’s therapy or only individual counseling?

The best way to reach out to your insurance provider is to call the phone number that’s listed on the back of your insurance card.

Reach out to a therapy practice

If you believe that your insurance covers therapy but aren’t sure about the specifics, the best and most hassle-free way to get more information on your coverage is to reach out to a therapy practice.

Therapy practices have billing and administrative staff who are experts in navigating the intricacies of insurance coverage and policies. They can reach out to your insurance company on your behalf, file claims on your behalf, and inform you of any copays or coinsurance that you must pay.

At Westmoreland Psychotherapy Associates, we accept the following insurance plans:

  • Highmark BC/BS Commercial Plans

  • UPMC Commercial Insurance Plans

  • United Healthcare/Optum Commercial Plans

  • Geisinger Health Plan Commercial Plans

  • Cigna Commercial Plans

  • Self-payment without insurance is also accepted

If you’d like to learn more about how we can work with your insurance to cover your treatment plan, reach out to us today. We would be happy to partner with you in navigating the intricacies of health insurance coverage. Contact us today to get started.


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