Paul Sanchez
Whether or not therapy is covered by medical insurance is a complex question. While federal law requires most insurers to provide parity between mental health and medical benefits, this does not necessarily mean that therapy will be covered by insurance. Many health plans cover therapy to varying degrees, but some therapists do not accept insurance, and some types of therapy are not covered by insurance. Furthermore, there may be limits to the number of therapeutic visits covered annually. It is important for individuals to carefully review their insurance plan details and contact their insurance provider to determine if therapy is covered and to what extent.
| Characteristics | Values |
|---|---|
| Whether therapists count as specialists under medical insurance | Depends on the insurance provider and the type of therapy |
| Whether therapy is covered by insurance | Yes, but not always. Many health plans cover therapy, but some do not. |
| Whether all therapists accept insurance | No, some therapists do not accept any insurance, and some accept only certain types of insurance. |
| Whether all types of therapy are covered by insurance | No, some types of therapy, such as hypnotherapy, are not typically covered by insurance. |
| Whether there are limits to therapy covered by insurance | Yes, there may be limits to the number of therapeutic visits or the duration of therapy covered by insurance. |
| Whether therapy requires a medical diagnosis or diagnostic code | Yes, insurers usually require a diagnosis to be made before covering therapy. |
| Whether therapy is more accessible with or without insurance | With insurance, therapy may be more affordable, but it may be easier to get an appointment with a therapist who does not accept insurance. |
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What You'll Learn
Some therapists don't accept insurance
While most therapists would like to help people in need, they also have to pay the bills. Typical costs of business for therapists include renting office space, advertising, liability insurance, and student loans associated with having a high level of education. This is why some mental health professionals accept insurance at the beginning of their careers while they are building clientele, and then scale down or stop working with insurance companies once they’ve established themselves.
The process of working with insurance companies can be time-consuming and bureaucratic. Therapists have to fill out paperwork, make phone calls, and wait for reimbursement – all while balancing a busy caseload. This can take away from valuable time that could be spent with clients or on professional development. Therapists are also typically paid very little by insurance companies, usually between 50-60% of their standard fee. While your therapist may charge $120 as their standard rate, that means insurance companies would only pay the therapist $60-70. Less income from insurance companies means more clients are required to fill the therapist’s case load so the therapist can support themselves, which can quickly lead to burnout and subpar care.
Insurance companies also have their own rules and regulations when it comes to mental health coverage. They may limit the number of sessions you can have, require specific diagnoses to be made, or dictate the type of therapy that can be used. This can be challenging for therapists who want to provide the best possible care for their clients without being restricted by these requirements. Insurance companies are more interested in their own interests than what is helpful to the client.
Some therapists who don't take insurance offer sliding-scale fees or other payment options to make therapy more affordable. This can be especially helpful for clients who are facing financial hardship.
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Mental health parity laws require equal coverage
The parity law applies to clinical criteria used by health insurers to approve or deny mental health or substance use treatment. The standard for medical necessity determinations—whether the treatment is considered reasonable, necessary, and/or appropriate—must be made available to any current or potential health plan member upon request. This means that if a plan offers unlimited doctor visits for a chronic condition like diabetes, it must also offer unlimited visits for a mental health condition like depression.
The MHPAEA also prohibits separate financial requirements and treatment limitations that apply only to MH/SUD benefits. This means that a plan cannot charge a higher copayment for mental health services than it applies to two-thirds of medical/surgical services. For example, if a health plan has a $20 copay for seeing an allergist, it cannot require a $40 copay for seeing a psychotherapist. The benefits must be equal or better.
The MHPAEA does include a cost exemption provision that allows plans to apply for a temporary exemption from compliance if costs exceed a certain threshold in a given plan year. Additionally, the law does not apply directly to small group health plans, although its requirements are applied in connection with the Affordable Care Act's EHB requirements. The Affordable Care Act requires coverage of mental health and substance use disorder services as one of ten essential health benefits in non-grandfathered individual and small group plans.
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Diagnosis may be required for insurance coverage
In the United States, the mental health parity law requires health insurance companies to cover mental health, behavioural health, and substance use disorder services. This law is designed to prevent insurance companies from charging higher copays for office visits to a therapist than they would for a typical check-up at a doctor's office. It also removes annual limits on the number of therapy visits covered. However, insurance companies can determine what constitutes a medical necessity for mental health treatment.
While federal and state laws mandate accessible mental health treatment, some insurance companies may deny claims if they deem the treatment was not medically necessary. In such cases, individuals can appeal the insurance company's decision. The appeal process depends on the type of insurance held, but appeals can be made to the Federal Center for Medicaid and Medicare Services or the U.S. Department of Labor. These entities can enforce the parity law and assist in obtaining coverage for therapy costs.
It is important to note that not all therapists accept insurance, and those who do may only accept certain plans. Solo practitioners, in particular, may not accept insurance or may limit the number of plans they take. If a therapist does not accept your insurance, you may have to pay for the visits yourself and then submit a claim to your insurance company for reimbursement.
To determine if your insurance covers therapy, it is recommended to start by reviewing your health plan's website or contacting your insurance provider. Understanding your mental health benefits and any applicable limitations can help you make informed decisions about seeking therapy.
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In-network therapists may be harder to book
Therapists who are in-network may also have high demand for their services, leading to long wait times for new patients. This can be frustrating for individuals seeking therapy, as they may have to call numerous in-network therapists before finding one with availability. The process of navigating health benefits and understanding coverage can also be complex and time-consuming, especially for those already struggling with their mental health.
Furthermore, using in-network insurance gives the insurance company a say in the choice of therapist. If an individual's insurance changes, they may need to switch providers, which can be disruptive to their treatment journey. Some therapists may also prioritize opportunities outside of insurance to maintain autonomy over patient care and offer more affordable services.
It is worth noting that out-of-network benefits can provide alternatives. Some therapists work on an out-of-network basis, and insurance plans may reimburse members for a portion of the cost. However, it is important to recognize that therapy, even with insurance, can still be costly, and individuals should consider their specific plans and financial situations when making decisions about their mental health care.
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Out-of-network therapists may be more costly
However, there are a few reasons why you might choose to see an out-of-network therapist. Firstly, it can often be difficult to find a therapist who is accepting new patients, and out-of-network therapists may be available more quickly. Secondly, you might find an out-of-network therapist who specializes in something you are struggling with or who meets other needs, such as being located nearby. Thirdly, out-of-network therapists may be able to offer more individualized or niche care. For example, they might be willing to accompany a client with agoraphobia to the grocery store or talk on the phone during a panic attack.
It's important to note that not all therapists accept insurance, and some may not accept your specific insurance plan. Therefore, it is essential to do your research beforehand to understand how much you will be paying and whether you will be reimbursed by your insurance company.
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Frequently asked questions
It depends on your insurance provider and your specific plan. Many health plans cover therapy, but not all. Some therapists also don't accept insurance, so it's important to check with both your insurance provider and your therapist.
You can check your health insurance plan’s website for information about your coverage and costs. If you're insured through your employer, you can also contact your human resources (HR) department.
If your therapist doesn't accept your insurance, you may have to pay for the visits yourself and then submit a claim to your insurance company for reimbursement.
