Questions to Ask Your Insurance Company Before You Start Therapy

Most people find out what therapy will cost them after the first session. It does not have to work that way. One phone call, ten minutes, gets you a number you can plan around.

Your insurance card has a member services number on the back. Call it, say you want to ask about outpatient mental health benefits, and work through the list below. Have your member ID in front of you.

Write down the representative's name and the reference number for the call. Ask for both. If you are told something that later turns out to be wrong, that reference number is the only thing that makes the conversation provable.

1. Do I have out-of-network benefits for outpatient mental health?

This is the gate. If the answer is no, nothing below applies. HMO and EPO plans often have no out-of-network coverage at all. PPO and POS plans usually do.

2. Is telehealth covered the same as in-person for out-of-network providers?

Some plans still treat the two differently, and most therapy is now delivered by video. Ask specifically; do not assume.

3. What is my out-of-network deductible, and how much of it have I met this year?

This is a separate number from your in-network deductible and it is usually higher. It typically resets in January. If you are calling in November, the answer may be very different from the answer in February.

4. Once the deductible is met, what percentage do you reimburse?

This is coinsurance. Sixty to eighty percent is common.

5. Is that percentage based on what my provider charges, or on an allowed amount?

This is the question almost nobody asks, and it is the one that decides the actual dollar figure. Most plans reimburse a percentage of an allowed amount they set themselves — sometimes called the recognized charge, or reasonable and customary — not a percentage of your therapist's fee. If the allowed amount is lower than the fee, your reimbursement is calculated on the lower number.

Then ask: what is the allowed amount for CPT code 90837 in my ZIP code?

90837 is a 60-minute individual psychotherapy session. The codes you may also hear are 90834 for 45 minutes, 90791 for an initial evaluation, and 90847 for family or couples therapy with the client present. Naming the code and the ZIP code is what gets you a real number instead of a range.

6. Do I need preauthorization or a referral?

Rare for outpatient therapy, but not unheard of, and it is cheap to rule out.

7. How do I submit a claim, and what is the deadline?

Most plans take claims through a member portal or a mailed form. Filing deadlines run anywhere from ninety days to a year from the date of service. Ask which, and note it.

8. Is there an out-of-pocket maximum, and do out-of-network costs count toward it?

Often there is a separate out-of-network maximum. It matters if you expect to be in treatment for a while.

9. Do I have an EAP benefit, and does using it affect any of the above?

Some employers provide a set number of covered sessions through an employee assistance program that sits outside your regular plan.

What to do with the answers

You now have four numbers: your out-of-network deductible, how much of it you have met, your coinsurance percentage, and the allowed amount for the session length you expect. Those four numbers tell you what a session will actually cost you. We explain how they fit together in How Out-of-Network Therapy Benefits Work.

If working through it alone is more than you want to take on, tell us what your plan said and we will walk through it with you before anything is booked.

This is general information about how insurance plans commonly work, not advice about your specific policy. Your plan documents and your insurer are the authority on your coverage.