What are out-of-network benefits?

Out-of-network benefits for mental health counseling refer to the part of your health insurance plan that helps pay for services provided by therapists who do not have a contract with your insurance company.

In-Network vs. Out-of-Network

In-Network Providers: These therapists have a contract with your insurance company to provide services at a negotiated rate.

Out-of-Network Providers: These therapists do not have a contract with your insurer. You can still see them, but you will need to submit your own claims for reimbursement.

How Out-of-Network Benefits Work

1. Depending on you plan there may be a deductible to be met before these benefits start. Sometimes there is no deductible.

2. Your bottom-line out of pocket expense will depend on your coinsurance amount. This is the percentage of the fee you are ultimately responsible for. This percentage varies depending on your plan.

3. You pay your therapist directly.

4. You submit a claim to your insurance company (usually with a superbill from your therapist).

5. Your insurer reimburses you a percentage of the allowed amount (not necessarily what you paid). The allowed amount is the maximum price the insurance company recognizes for a service. If the out-of-network provider charges more than your plan's allowed amount, you may be responsible for paying the difference in addition to your coinsurance and deductible.

Example:

If:
• Your therapist charges $175/session.
• Your plan reimburses 60% (coinsurance) of the allowed amount of $175.
• Your coinsurance responsibility is 40%.
• You’ve met your out-of-network deductible.

Then:
• Insurance reimburses: 60% of $175 = $105. You pay: $70 out of pocket.

If the insurance allowed amount is lower than the therapist’s fee, you pay your coinsurance plus the difference between the fee and the allowed amount.

What to ask your insurance about out-of-network benefits

When talking to your insurance company about out-of-network benefits for mental health counseling, it’s important to ask specific questions to understand your financial responsibility and claim process.

Here’s a list of questions to ask:
• Do I have out-of-network mental/behavioral health benefits?
• What percentage of the provider’s fee is reimbursed after the deductible is met?
• Do I have an out-of-network deductible that has to be met first before I get reimbursed?
• Has any amount of my deductible been covered this year?
• What is the usual and customary rate covered by my insurance for outpatient psychotherapy (CPT code 90834)?
• What is the process for submitting claims for reimbursement?

This page is for information purposes only and does not represent any financial agreement or practice policy. You are responsible to confirm the details of your policy with your insurance provider.