Finding a Therapist: All About Insurance
Understanding insurance can be overwhelming, but Psych Me Out is here to help! At times, therapy can be costly, however, many insurance companies have mental health benefits for you to choose from. If you are someone that is interested in using your health insurance benefits for therapy, testing, medication management or other psychological services, the terms below would be helpful to familiarize yourself with.
In order to determine what your benefits are, you can call the behavioral health member services number on the back of your insurance card. You may also be able to access some of this information through your insurance providers phone app. Note: your healthcare benefits are not always the same as your behavioral health benefits, so make sure that you specify this when searching.
TERMS TO KNOW
Deductible: The amount of money money you must pay before insurance will begin to cover some of the costs. There are two types of deductibles: individual and family. Individual is strictly for yourself, family will cover you plus your listed family members (spouse, children). Deductibles run by calendar year, therefore, the earlier in the year you meet the deductible, the sooner your insurance coverage will kick in. Generally speaking, lower deductibles are associated with higher monthly costs. For example, a person with a $500 deductible may pay $300/month for health insurance, whereas a person with a $750 deductible may pay $250/month.
Co-pay or co-insurance: The amount (co-pay, $25/session) or percentage you must pay (co-insurance; i.e., in a 60/30 split, you pay 30% of the fee per session). The lower the 2nd number in the co-insurance percentage, the less you pay. You may be charged this upfront, for example, paying a $30 copay before session, or this may be billed to you retroactively. Please check with your provider which option is used.
Out of pocket maximum: The total amount of money you must spend per calendar year before insurance pays 100% for the services.
In-network: If a provider is in-network, this means that they accept your insurance plan. When asking a provider about this, be specific! Sometimes, insurance companies may seem to have similar enough names, though are actually not the same company (ex. Aetna vs Aetna Better Health). If the provider is in-network, then your in-network benefits would apply.
Out-of-network: If a provider does not accept your insurance, then they are considered out-of-network. This means that your out-of-network benefits may apply. However, you should check with the provider and your insurance company to see if they will cover the service and apply those benefits. Note: sometimes when using out-of-network benefits, you may be required to pay out-of-pocket in full upfront, and then will get reimbursed by your insurance company once the billing is complete.
TYPES OF INSURANCE PLANS
Health Maintenance Organization (HMO): This is generally the most affordable and works best for people who do not have severe and/or chronic health problems. It tends to have lower monthly (or per paycheck) costs and may have fixed co-pays for visits. If you have this plan, you are only allowed to go to providers that are in-network and that accept your HMO plan. You may also need a referral from your primary care physician (PCP) to obtain other services.
Point of Service (POS): This plan is similar to that of an HMO, however, it allows you to see a doctor that is out-of-network if you have the appropriate referral from your PCP. This option, however, may increase your monthly cost and deductible.
Exclusive Provider Organization (EPO): These types of plans also only cover in-network providers, but provider a larger network of providers to choose from than an HMO would. Referrals may be provided by a PCP, though not always. This type of plan is generally more costly than an HMO.
Preferred Provider Organization (PPO): These plans have the highest monthly costs because they allow you to see out-of-network providers without a referral. The in-network benefits are usually quite low. This type of plan is best for those that need more flexibility in provider choice, can afford higher monthly costs, and for those that may have more severe or chronic illness that require specialists.