Insurance is confusing — even for professionals! This guide is here to help you understand your benefits, estimate your costs, and confidently talk with your insurance company so there are fewer surprises along the way. Being proactive about understanding your insurance coverage equips you to find a therapist that meets both your mental health needs and your financial situation. Taking the time to research and understand this information is a valuable investment in your well-being.
Are We In-Network With Your Insurance?
A therapist can be in-network with your insurance company but not your specific plan, so this should always be confirmed before proceeding.
When Art of Counseling or your provider is considered an “in-network” provider:
- You pay lower rates (if any)
- Insurance typically pays a larger portion of the bill
When Art of Counseling or your provider is considered an “out-of-network” provider:
- Although Art of Counseling or your provider might have a contract with your insurance company, they might not be considered an in-network provider for your specific insurance plan
- You will usually pay the full session fee up front
- Your insurance may reimburse you for part of the cost if you have out-of-network benefits (although this is not guaranteed)
Checking your Health Insurance for Mental Health & Therapy Benefits
Information to have ready before your call
Before you make the call, here is some information that will make your call go smoother and allow you to gather comprehensive details around your coverage. You can ask the therapist you are considering for this information when you have an initial call with them as well.
- Provider’s full name: Make sure to ask your provider for their full registered name. For example, while they may go by “Dr. Jane,” their full name in the healthcare system may be “Jane Doe.”
- Provider’s NPI: Every licensed therapist has a National Provider Identification number. You can ask your therapist for this prior to talking with your insurance.
- Art of Counseling has a group NPI (1801282173) that should be sufficient for the sake of your benefit call to confirm that your provider is in-network with your insurance plan since we bill as a group practice.
- Health insurance card: Have your health insurance card handy so you have the insurance company’s phone number, your Member ID number, and any other plan details you may be asked for.
- Full name and date of birth of the subscriber: If you are on your parents’ or spouse’s health insurance plan, you may want to have their name and DOB prepared and ready to provide.
- CPT Codes (nice to have): CPT stands for Current Procedural Terminology and refers to the type of treatment you are receiving. Ask your provider for which CPT codes you should provide. For example, 90791 for the intake appointment (Psychiatric/psychological diagnostic interview without medical services) or 90837 for ongoing therapy sessions (Individual psychotherapy).
Once you have all of this information, you can either conduct the insurance check by utilizing your insurer’s online portal or website, or you can call the “Member Services” number located on the front or back of your insurance card to talk with a representative who will be able to explain your coverage benefits more fully.
If you go the route of calling your insurance, follow the prompts to “Check Eligibility and Benefits” so that you get connected to the right representative.
Questions to ask your Insurance to Confirm Mental Health Benefits
The questions below should help you gather valuable information regarding your mental health coverage: We recommend you write down the answers and share them with an administrative staff member or your therapist who can help you understand what each of these mean.
- “Is (provider) at Art of Counseling in-network with my health insurance plan?”
- “What are my outpatient mental health benefits?”
- If you have a deductible
- “How much is my deductible?”
- “How much of my deductible have I already met?”
- “Will I be responsible for a co-pay or coinsurance after meeting my deductible?”
- “Do I have an out-of-pocket max? If so, how much have I already met?”
- If you have a co-pay
- “How much is my co-pay for outpatient mental health services?”
- “Do I have an out-of-pocket max? If so, will this outpatient mental health co-pay apply towards my out-of-pocket max?”
- If you have a deductible
- “Are telehealth/virtual mental health visits covered? If so, are they covered the same as in-person visits?”
- “Can I get a reference number for this call?”
Collecting and reference numbers for these conversations may become useful if you need to follow up with insurance regarding an appeal or
If the provider or Art of Counseling is NOT in-network with your health insurance plan, you may have out-of-network benefits through your insurance. This is something you can inquire about by calling the same “Member Services” number on your insurance card or by utilizing your health insurer’s online portal or website. They should also be able to provide you a list of providers who are in-network with your insurance plan.
Insurance Terminology
Use the list as a reference for the different terms that could be used in conversation with your insurance carrier to confirm and clarify your coverage and benefits.
Deductible
A deductible is the amount you pay out of pocket before your insurance begins covering costs.
Example: Your deductible is $1000, and you have not put any medical bills towards it yet. You just received a medical bill for $1200. You will have to pay $1000 to meet your deductible, and you will pay a coinsurance for the rest of the bill.
Coinsurance
If your insurance plan has a deductible, you will have a coinsurance. A coinsurance is the percentage of a doctors bill you pay after you’ve already met your deductible.
Example: If you have a deductible of $2000, and you’ve already met that deductible, you’re now only responsible for your coinsurance for the rest of the doctors appointments you have that year. So if you go to the doctor and it costs $500, if your insurance card says your coinsurance is 25%, you would pay $125. (125 is 25% of 500)
Co-Pay / Co-Payment
A co-payment (co-pay) is the amount of money that you are required to pay for medical services or medication. Your co-pay can be different for different services, so be sure to check with your insurance before seeing your provider. This is different from coinsurance because a coinsurance is a percentage of your doctors bill, while a co-pay is a flat rate.
Coverage Limits
This includes restrictions on services your insurer will pay for, like allowing only 10 therapy sessions per year before out-of-pocket costs apply.
Prior Authorization
Some services require prior authorization, meaning you must get your insurer’s approval before starting them.
Coverage Limits
Some insurances place certain coverage restrictions on particular services. This varies by insurance and individual insurance plan.
Example: Some insurances might cover up to 10 therapy sessions per year at 100% before a deductible, co-pay, or coinsurance applies.
Explanation of Benefits (EOB)
An EOB is a statement from your insurer breaking down treatment costs, what they paid, and what you owe. This is not a bill.
Out-of-Pocket Maximum (OOP Max)
Your out-of-pocket maximum is the maximum amount of money that you are responsible for paying during your insurance contract (one year) before your insurance company starts covering 100% of in-network medical charges. It’s important to note that your insurance premium (monthly charge for coverage) is NOT included in your out-of-pocket costs, so do not include your premium if you’re trying to calculate how close you are to reaching your out-of-pocket maximum.
Example: If your out-of-pocket maximum is $2000, and you’ve already paid $1800 out-of-pocket for medical bills this year, you are $200 away from your out-of-pocket maximum. If you now receive a doctor’s bill that is $500, you will only owe $200, and your insurance will cover the additional $300. This means for the rest of the year, your insurance will cover 100% of your medical bills. You will only be responsible for your premium. (This is not common, most people don’t hit their out-of-pocket maximum in the span of a year).
If you need additional support, don’t hesitate to reach out to your therapist or the administrative team at Art of Counseling to help you look into your mental health benefits further!