Paying Out of Pocket for Therapy? What to Know Before Open Enrollment
Open enrollment is coming, and it's worth looking deeper than just your monthly premium.
If you've been thinking about starting therapy but haven't been satisfied yet with your in network options, this is for you.
And if you're already seeing a therapist out of pocket, you may assume the upcoming barrage of emails don't matter for you.
But they are still worth paying attention to!
Your insurance company may offer out of network (OON) mental health benefits, and depending on your specific plan, you may be able to receive some reimbursement even if your therapist isn't in network.
It’s important to note that no provider can outright guarantee your reimbursement; Rules change often, and company to company differs in their process. But I do want you to feel informed and empowered to ask questions, and utilize benefits that you may already have.
First, what does "out of network" mean?
Simply stated: Your provider doesn't have a contracted rate with your insurance company.
There may be a lot of practical and professional reasons for this!
Without being overly critical: It's no secret how insurance companies prefer to operate, and sometimes there is much more "down side" for a provider in these negotiations that can intrude on professionalism, burnout, and quality of care.
Reimbursement- How does it work?
Your therapist charges their full session fee, which you pay at the time of your appointment. If your insurance plan includes out of network benefits, you may choose to submit a claim and your insurance company may reimburse you according to your plan's rules.
Most out of network providers are happy to provide something called a Superbill: a monthly statement of services rendered, which you have paid already upfront.
This Superbill is the claim you are submitting to your insurance, if you decide to tap into those benefits. [Submitting Superbills is optional, not a requirement to work with me or anyone else. But you should know your options!]
The payments you've made go towards your deductible -- and once that deductible is met, you can begin receiving a percentage of future costs back in the mail.
In some plans, you may also see something called "coinsurance." This is the percentage of the allowed amount you're responsible for after the deductible is reached. Example: If you've met your deductible and your coinsurance is 20%, then you would now start to pay 20% of the allowed amount, while your plan pays the other 80%.
You don't have to figure it out before reaching out
Insurance benefits can be confusing, and it's very reasonable to have questions.
If you're considering therapy with me, you're welcome to ask for more information -- you don't have to have it completely figured out already.
I truly want you to do what's best for you and make an informed decision, while taking advantage of the benefits that are available, if you want to.
Why do some people choose an out of network therapist?
A few reasons come to mind:
You aren't limited to therapists who participate with your insurance, who may or may not be the best match. You should have the right to consider experience, specialty, personality, location, availability, and overall fit for your needs and preferences.
Increased privacy: not forcing a diagnosis or sharing certain aspects of your treatment in order to "prove" that your sessions should be covered. ...to a company whose job is to contain costs as much as possible.
Your therapist can be completely focused on YOU -- no distractions of meeting paperwork requirements, wondering how many weeks or months it will take to be paid for their work, and navigating other red tape (created by someone who doesn't know your situation) that contribute to resentment and burnout.
The understanding that you may not have to fully choose between private pay and insurance: Out of network benefits could give you the best of both worlds!
Open Enrollment is coming!
Let's be prepared and informed this year.
Your premium matters, but so does having a plan that's functional for your real life, supporting your personal goals and needs.
Considering therapy in Cresskill, NJ?
I provide therapy for adults and young adults in Cresskill, and virtually throughout New Jersey and Connecticut.
If you're considering getting started but have questions about fees or out of network benefits, you are welcome to reach out HERE.
You can also plug your insurance info directly at the bottom of my FAQ page to run your benefits immediately!