Therapists: Insurance-Covered Specialists?

Whether a therapist is considered a specialist for insurance purposes depends on the insurance plan. Some insurance plans cover therapy, but not all. The federal parity law requires health plans that offer mental health coverage to offer comparable benefits to medical coverage. This means that if your insurance has a $20 copay for seeing an allergist, it can't require a $40 copay for seeing a psychotherapist. The benefits must be equal or better.

The federal parity law applies to employer-sponsored health plans for companies with 50 or more employees, individual health plans purchased through the health insurance exchanges created under the Affordable Care Act, and the Children's Health Insurance Program. It does not apply to small companies with fewer than 50 employees, some state plans (such as those covering teachers), or Medicare.

The cost of therapy varies, with many providers in the United States charging between $65 to $200 per session. The cost depends on the location, the therapist's training, and any specialized care needed. Therapy is often covered by insurance with a co-pay, or it may be included in your deductible.

A therapist is considered a specialist and may cost more than a primary care physician

The short answer is yes. A therapist is considered a specialist and may cost more than a primary care physician.

The Mental Health Parity and Addiction Equity Act (MHPAEA)

The Mental Health Parity and Addiction Equity Act (MHPAEA) is a federal law that keeps group plans from offering different (or fewer) mental health benefits than they do medical or surgical benefits. This law was passed in 2008 and requires that insurance companies treat mental and behavioural health and substance use disorder coverage equally to (or better than) medical/surgical coverage.

The parity law requires that copays for mental health services are equal to or less than the copay for most medical/surgical services. For example, if you pay $20 to see your primary care physician but $40 to see your dermatologist, you can expect to pay the higher amount for a therapist as well. The average cost of therapy with insurance typically ranges from $20 to $50 per session, depending on your insurance coverage plan. Without insurance, therapy sessions can cost significantly more, often between $100 and $200 per session.

Some insurance plans have very high deductibles, and paying this amount may be a challenge. Your therapist might offer affordable payment plans to allow you to pay over a longer period. You might also choose not to use your insurance and instead find a therapist who offers sliding scale fees based on your income and ability to pay.

Insurance coverage for therapy depends on the specific plan

The cost of therapy can be a significant concern for those seeking treatment. While some therapists charge hundreds of dollars per session, there are also low-cost options available. The amount of coverage provided by insurance for therapy services depends on the specific plan. Here are some key points to consider:

Types of Insurance Plans

There are two main types of insurance plans when it comes to covering the cost of therapy: co-pay and deductible plans. With a co-pay plan, you pay a set amount for each therapy session, and your insurance covers the rest. On the other hand, a deductible plan requires you to pay all your medical expenses up to a certain amount before your insurance starts covering a percentage of the costs. It is important to understand which type of plan you have and how it will impact your out-of-pocket expenses.

In-Network vs Out-of-Network Providers

Insurance plans typically have a network of therapists and mental health professionals who are considered "in-network." Visiting these in-network providers usually results in lower out-of-pocket costs. Going to an out-of-network therapist often means higher costs and less coverage. However, it might be necessary to go out-of-network if you need a specialist or if the in-network options are limited.

Coverage for Different Therapy Modalities

Different insurance plans may cover various forms of therapy, such as individual, group, or family therapy. The coverage may differ based on the type of therapy, so it is important to check what your specific plan covers. For example, marriage and couples counselling are generally not covered by insurance, but there are still affordable options available through online therapy platforms.

Telehealth Options

Many insurance plans now include coverage for telehealth services, which can include online therapy. This can be a convenient and affordable option for accessing mental health services, especially for those in rural areas or with mobility issues. However, insurance typically does not cover therapy costs through specific online therapy companies like Talkspace and Better Help.

Understanding Your Plan

To determine if your insurance covers therapy and what your out-of-pocket costs will be, it is essential to review your plan details. Check your insurance account online or call your insurance provider to get specific information about your coverage. Additionally, your Human Resources (HR) department can be a valuable resource if you have insurance through your employer. They can help you understand your coverage and answer any questions you may have.

The Mental Health Parity Act of 2008 keeps group plans from offering fewer mental health benefits than medical or surgical benefits

The Mental Health Parity and Addiction Equity Act (MHPAEA) was passed in 2008 to address the historical differences in insurance coverage for mental health and substance abuse benefits and medical/surgical benefits. The Act prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favourable benefit limitations on those benefits than on medical/surgical benefits.

The MHPAEA was an expansion of the Mental Health Parity Act of 1996, which prohibited the use of special annual and lifetime dollar limits on mental health benefits. However, insurers were able to circumvent this legislation by tightening restrictions on the number of hospital days and outpatient visits for mental health services. The 2008 Act addressed this loophole by requiring that if a group health plan or health insurance coverage includes medical/surgical benefits and MH/SUD benefits, the financial requirements (e.g. deductibles and copayments) and treatment limitations (e.g. number of visits or days of coverage) that apply to MH/SUD benefits must be no more restrictive than those that apply to medical/surgical benefits.

The MHPAEA also includes protections for out-of-network coverage. Health plans that provide out-of-network coverage for medical/surgical benefits must also provide equal out-of-network coverage for MH/SUD benefits.

The MHPAEA does not require insurers to provide mental health benefits. However, if they choose to do so, these benefits cannot have more restrictive requirements than those that apply to physical health benefits. This means that insurers cannot charge higher copays for therapy than for other specialist visits, for example.

The MHPAEA applies to employer-sponsored health coverage for companies with 50 or more employees, coverage purchased through health insurance exchanges created under the Affordable Care Act, the Children's Health Insurance Program (CHIP), and most Medicaid programs. It does not apply to small companies with fewer than 50 employees, some state plans (such as those covering teachers), or Medicare.

The Affordable Care Act (ACA) requires that plans purchased through the Health Insurance Marketplace include mental health services

The Affordable Care Act (ACA) was signed into law by President Barack Obama in March 2010. It is a comprehensive healthcare reform designed to extend health coverage to millions of uninsured Americans. The ACA requires insurers to cover a list of essential health benefits, which include:

• Emergency services
• Family planning
• Maternity care
• Hospitalization
• Prescription medications
• Mental health services
• Pediatric care

Under the ACA, mental and behavioral health services are considered essential health benefits. The law requires that plans purchased through the Health Insurance Marketplace include mental health services and substance use disorder services. This includes individual plans, family plans, and small business plans.

The ACA also mandates parity protections, ensuring that copays, coinsurance, and deductibles for mental health services are the same or similar to those for medical and surgical benefits. This means that insurers cannot charge higher copays for therapy than they do for other specialists.

It is important to note that the ACA does not require insurers to provide coverage for mental health. However, if mental health benefits are offered, they cannot have more restrictive requirements than those that apply to physical health benefits.

The ACA has improved access to mental health services, but it is still important to understand your specific plan's coverage and any associated costs. Plans may vary in terms of which therapies are covered, out-of-pocket costs, and whether they cover in-network or out-of-network providers.

To determine if your insurance covers therapy, you can check your insurance account online, call your insurance provider, or ask your employer's Human Resources department.

In-network therapists usually result in lower out-of-pocket costs

The cost of therapy can be daunting, especially when you are unsure whether your insurance covers it. The good news is that therapy may be more accessible and affordable than you expect with the help of insurance coverage.

In-network therapists have a contract rate with your health insurance provider and have negotiated what they will earn through your insurance network. When you see an in-network therapist, you pay a predetermined co-pay upfront, and your insurance company pays the rest of the fee to your provider later.

Seeing an in-network therapist usually results in lower out-of-pocket costs because you only owe a co-pay at the time of your session. The co-pay amount varies depending on your insurance plan and can range from $15 to $85 or more. Your insurance company will pay your therapist the rest of what they deem a reasonable rate for the service provided.

Many therapists list on their website which insurances they accept. You can also call your insurance company or visit their website and ask for the names of therapists in their network. You can also ask your employer's HR department for a list of in-network therapists.

If you can't find an in-network therapist, you may want to consider seeing an out-of-network therapist. Out-of-network therapists do not have a contract rate with your health insurance provider and set their own professional fees. Seeing an out-of-network therapist will usually result in higher out-of-pocket costs, but there are still ways to reduce these costs. For example, you can use your health insurance plan's out-of-network benefits or ask the therapist if they offer a sliding scale fee.

Frequently asked questions