Understanding Therapy Copays: Navigating Your Insurance Coverage

The cost of therapy can be a deterrent for many people seeking mental health treatment. While insurance is required to cover mental health services, including therapy, it is only for \medically necessary\ therapy. To find out your insurance copay for therapy, you can start by reviewing your insurance policy, specifically your Explanation of Benefits (EOB), which should list the cost of mental health services, including therapy, under allowed amount. You can also contact your insurance company directly, as copay amounts can vary depending on your location, insurance provider, and therapist. Additionally, online tools such as Alma's free directory and cost estimator can help you find providers who accept your insurance and calculate your expected copay.

Understanding copay, coinsurance and deductibles

Understanding copay, coinsurance, and deductibles is essential to knowing your insurance coverage and out-of-pocket costs. These terms determine how costs are shared between you and your insurance company. Here's a detailed explanation of each:

Copay (or Copayment):

A copay is a fixed or flat fee that you pay each time you visit your doctor, receive medical treatment, or fill a prescription. It is a predetermined rate based on your health insurance plan and is usually printed on your health plan ID card. Copays are typically due at the time of service and remain the same regardless of whether you've met your deductible. They can vary depending on the type of healthcare service, with preventative care often having a lower copay than urgent care.

Coinsurance:

Coinsurance is the percentage of the cost of health services that you pay after you have met your deductible. In other words, it is your share of the cost of covered medical expenses. For example, if your insurance plan covers 80% of a particular service, you will be responsible for paying the remaining 20% as coinsurance. The specific coinsurance rate can vary depending on the service and your insurance plan.

Deductible:

A deductible is the amount you must pay out-of-pocket for covered medical services before your insurance company starts sharing the cost. It is separate from your monthly premium payments. For example, if you have a $2,000 yearly deductible, you will need to pay the first $2,000 of eligible medical expenses yourself before your insurance plan begins to contribute. Deductibles can vary significantly, ranging from hundreds to thousands of dollars, depending on the plan and type of coverage (individual or family).

To find out your specific copay for therapy, you can review your insurance policy's Explanation of Benefits (EOB) or contact your insurance company directly. Additionally, tools like Alma's Cost Estimator Tool can help you calculate your expected costs.

In-network vs out-of-network therapists

When it comes to choosing a therapist, you may be wondering whether to go with an in-network or out-of-network provider. Here are some things to consider when making your decision:

In-Network Therapists

In-network therapists are those who are part of your insurance company's network or directory. This means they have agreed to provide services to people with your insurance plan, and the fees for these services are set by the insurance company. Many therapists are qualified to treat common mental health challenges, such as anxiety or depression, and may be able to offer a range of therapeutic approaches.

However, one potential downside of in-network therapists is that they may be limited in the frequency and duration of care they can provide due to insurance company guidelines. Additionally, you may have a high deductible, which means you will need to pay out of pocket until you reach a certain amount, after which your insurance coverage will kick in.

Out-of-Network Therapists

Out-of-network therapists are not part of your insurance company's network. They may be specialists with niche practices and extensive training in specific areas. They are not limited by insurance company guidelines, so they can offer longer, more frequent sessions and more creative treatment plans.

The main advantage of seeing an out-of-network therapist is that you may be able to receive reimbursement from your insurance company, making it more affordable. This is especially true if you have good out-of-network benefits, which can provide significant cost savings.

How to Know Your Copay

To find out your copay for therapy, you can start by reviewing your insurance policy, specifically your Explanation of Benefits (EOB). Here, you should be able to find the cost of mental health services, including therapy, listed under "allowed amount." If you cannot access your EOB, you can use free online tools, such as Alma's Cost Estimator Tool, to quickly calculate your copay. Alternatively, you can contact your insurance company directly to inquire about your copay for therapy services.

It is important to note that your copay for therapy should not be much higher than it would be for any other medical specialist, thanks to federal and state parity laws. Additionally, if you have a Medicare Advantage (Part C) plan, it will automatically cover therapeutic services at the same level or greater than original Medicare.

Calculating your therapy costs

The cost of therapy can be a deterrent for many people seeking mental health treatment. However, there are several ways to calculate your therapy costs and understand your insurance coverage. Here are some steps to help you determine your out-of-pocket expenses for therapy:

Review your insurance policy:

Start by reviewing your insurance policy, specifically your Explanation of Benefits (EOB). Your EOB should outline the cost of mental health services, including therapy, under the "allowed amount" or "contracted rate." This document will help you understand what services are covered and what your financial responsibility will be. You can request a copy of your EOB from your insurer if you don't have one.

Understand co-payments and deductibles:

Co-payments, or co-pays, are the set fees you pay per therapy session. The amount of your co-pay depends on your specific insurance plan and therapist. In-network therapists have agreed to accept the rate set by your insurance company, so your co-pay will likely be lower. Out-of-network therapists may charge higher fees, and your insurance may reimburse you for a portion of the cost. Deductibles refer to the amount you must pay out-of-pocket before your insurance company starts contributing to your treatment costs. Your co-pays may contribute to meeting your deductible.

Contact your insurance company:

If you have questions about your coverage, don't hesitate to contact your insurance company directly. They can provide you with specific details about your plan, including co-pays, deductibles, and in-network providers. You can also ask about any limits or requirements, such as referrals or treatment plans, that may be necessary for coverage.

Utilize online tools:

Several organizations offer online tools to help estimate therapy costs. For example, Alma provides a free Cost Estimator Tool that calculates your co-pay and tracks your progress towards meeting your deductible. TheraThink is another resource that offers mental health insurance billing services to help practitioners and patients navigate insurance billing.

Consider in-network therapists:

Choosing an in-network therapist can significantly reduce your therapy costs. In-network therapists have agreed to accept the rates set by your insurance company, resulting in lower co-pays for you. Out-of-network therapists may charge higher fees, and your insurance coverage may be more limited.

Explore alternative options:

If you're facing challenges with insurance coverage or affordability, there are alternative options available. For example, organizations like Give an Hour provide barrier-free access to therapy services for veterans, rare disease caregivers, and individuals affected by traumas. Additionally, online therapy platforms like BetterHelp and SonderMind offer potential cost savings and flexible payment options.

Contacting your insurance provider

If you receive your insurance through your employer, your HR department may be able to help. Mental Health America also provides a list of questions you can ask your insurer, such as whether you need a referral from your primary care physician to see a mental health professional.

It is important to note that the cost of therapy varies depending on location, insurance provider, and therapist. In-network therapists are likely to be cheaper, as they have agreed to accept the rate an insurance company is willing to pay per session. Choosing an in-network therapist through insurance may cost between $20 and $30 per session, but this could be as low as a few dollars or upwards of $50 depending on your location and therapist. If you choose an out-of-network therapist, you may have to pay the full amount, although your insurance company may reimburse you for part of the cost.

Finding a therapist that accepts insurance

It is important to note that not all insurance plans cover therapy, and those that do may have limits. To find out if your insurance covers therapy, you should review your insurance policy, specifically your Explanation of Benefits (EOB). If you are unsure, you can call or write to your insurance company to ask.

If your insurance covers therapy, you can then look for a therapist who accepts your insurance. Some therapists do not accept insurance, and those who do may require you to stay within a network of mental health professionals. A good place to start your search is with your insurer's network of mental health professionals. The American Psychological Association also provides a list of psychologists by ZIP code, and there are various online tools that can help you find a therapist who takes your insurance, such as:

• Headway: A platform that filters through therapists and psychiatrists to find your matches. You can add your insurance details, and the platform will estimate your cost.
• Grow Therapy: A platform that connects clients, therapists, and insurance companies to make mental healthcare simple to access.
• Alma: A platform with a free directory that can connect you with providers who take your insurance.
• Mental Health Match: A community of licensed and credentialed therapists that offers a free matching tool to help you find a therapist who is a good fit.
• Theravive: A list of affordable licensed therapists and counselors.

Frequently asked questions