If you’re one of the millions of Americans who are considering therapy, health insurance coverage may be a concern. If you have health insurance, chances are good that your policy provides some level of coverage.
To address the importance of and demand for sustaining mental wellness, most insurance companies offer some coverage for mental health services. But there are large differences between the benefits health insurers provide and the out-of-pocket costs you might be required to pay.
If you have health insurance through your job, it may or may not include coverage for therapy. Even if you have coverage, it’s up to you to decide whether or not you wish to use it for mental healthcare. In some instances, people choose to pay out of pocket for therapeutic services rather than claim coverage through their insurer. Why?
Insurance companies only pay for medically necessary services. They require a mental health diagnosis before they will pay claims. Some people are not comfortable with this.
A mental health condition diagnosis may range from acute stress to insufficient sleep syndrome, various phobias, mental illnesses, or a number of other descriptors. When it comes to insurance, each of these would have a code number that would go with an insurance claim.
Employer-sponsored insurance in companies of 50+ employees
Companies of 50 or more full-time workers are legally mandated to provide health insurance. This mandate does not specify that mental health services be included as a benefit. Even so, most large companies, including those that are self-insured, do provide health insurance that includes some coverage of therapeutic services.
Employer-sponsored insurance in companies under 50 employees
Small companies that employ under 50 people are not legally required to provide health insurance to their employees. However, for those who do, mental health services and substance use disorder services must be included, no matter where or how the plan is purchased.
Health Insurance Marketplace plans
Under the Affordable Care Act, all plans purchased through the Health Insurance Marketplace must cover 10 essential health benefits. These include mental health services and substance use disorder services.
All Marketplace plans, whether they’re state or federally managed, include coverage for mental health. This pertains to individual plans, family plans, and small business plans.
Plans and their coverage vary by state. States also offer multiple plan options, which vary in terms of their coverage.
All Marketplace plans must include
- behavioral health treatments, such as psychotherapy and counseling
- mental and behavioral health inpatient services
- coverage for pre-existing conditions
- no yearly or lifetime dollar limits on mental health coverage
- parity protections so that the copays, coinsurance, and deductibles for mental health services are the same or similar to those for medical and surgical benefits
CHIP (Children’s Health Insurance Program)
CHIP provides federal funding to states so that they can provide low-cost health insurance for low-income households with children who aren’t eligible for Medicaid. CHIP coverage varies from state to state, but most provide a full array of mental health services, including:
- medication management
- social work services
- peer supports
- substance use disorder treatments
The Mental Health Parity and Addiction Equity Act (MHPAE) requires most CHIP programs to provide parity protections for mental health and substance use disorder services. This ensures that copays, coinsurance, and deductibles for therapy and other mental health services are the same or comparable to those for medical and surgical benefits.
All state-run Medicaid plans are required to cover essential health benefits, including mental health and substance use services. Medicaid plans vary by state to state, but are also subject to the MHPAE.
Original Medicare covers inpatient behavioral health and substance use services under Part A. If you’re hospitalized, you may have a deductible per benefit period as well as coinsurance costs.
Outpatient mental health services, including an annual depression screening, are covered under Part B. You may incur out-of-pocket costs for therapeutic services, including the Part B deductible, copays, and coinsurance.
If you have a Medicare Advantage (Part C) plan, it’ll automatically cover therapeutic services at the same level or greater than original Medicare. Your costs may vary from those associated with original Medicare.
Register and log on to your insurance account online
Your health insurance plan’s website should contain information about your coverage and costs you can expect. Since insurers offer a variety of plans, make sure you’re logged on and viewing your specific insurance plan.
If you’re required to choose a therapist that’s in your plan’s network, a list of providers should be available online. You can also call and ask that a local list be given to you by phone or mail.
Call your insurance provider
If you need additional information, call the toll-free number on the back of your insurance card and ask questions about the types of therapeutic services you can expect coverage for, as well as any out-of-pocket costs you may incur. If you have a diagnostic code, that may help you get accurate information.
Check with your company’s HR department
If you’re insured through employment and need additional help, contact your human resources (HR) department, if you feel comfortable doing so.
Ask the therapist if they accept your insurance
Therapists and other providers often change the insurance plans they’re willing to accept and may have opted out of your plan.
First, you can’t be penalized for having a pre-existing condition or prior diagnosis of any type of mental illness. For that reason, you should be entitled to mental health services from day one of your plan’s start date.
Things that might affect when insurance coverage kicks in:
- After prior authorization. Some services may require pre-authorization before you can obtain coverage for them.
- After meeting a deductible. You may also have to meet an out-of-pocket deductible before your plan starts to cover therapy. Based on the type of plan you have, this amount may be significant.
- After spending a minimum. In some instances, your plan may require that you pay a specified dollar amount on medical services before your coverage for therapy can start.
Some mental health services that may be covered by insurance include:
- psychiatric emergency services
- co-occurring medical and behavioral health conditions, such as coexisting addiction and depression. This is often referred to as a dual diagnosis.
- talking therapies, including psychotherapy and cognitive behavioral therapy
- unlimited outpatient sessions with a psychiatrist, clinical social worker, or clinical psychologist. In some instances, your insurer may cap the number of visits you’re allowed annually — unless your provider states in writing that they’re medically necessary for your care.
- telemedicine and online therapy
- inpatient behavioral health services received in a hospital or rehabilitative setting. Your plan may limit the length of your stay, or cap the dollar amount they’ll pay for your care per benefit period.
- addiction treatment
- medical detox services, including medications
Insurers only cover treatments that are considered medically necessary.
The breadth of coverage for specific therapeutic treatments, such as the length of rehab or hospital stays, also varies from plan to plan. So does the coverage and cost for medications you might be prescribed to treat your condition, both as an inpatient and as an outpatient.
If you’re planning on using insurance to pay for couples counseling, the rule requiring a mental health diagnosis will continue to apply and require that one partner receive a mental health disorder diagnosis. Some people feel this has the potential to skew their therapeutic experience.
As with any diagnosis you receive, a mental health disorder diagnosis may remain in your permanent record. In some instances, it may be accessed by background checking systems for your entire life.
Since insurers offer an array of plans, it’s not possible to give the specifics of each plan they cover. Here are some examples of coverage you may be able to get for therapy from specific insurers:
Does Blue Cross Blue Shield cover therapy?
The vast majority of Blue Cross Blue Shield insurance plans cover therapy.
If, however, your plan started before 2014 (when the Affordable Care Act was enacted) your plan may not cover therapy.
Blue Cross Blue Shield only covers evidence-based therapeutic services, such as psychoanalysis.
It doesn’t cover therapeutic services provided by a life coach or career coach.
It also doesn’t cover therapeutic services provided outside of a therapeutic setting, such as therapist-led systematic desensitization for phobias. These types of sessions may take place in a variety of locations, such as in a car if you have a phobia of driving, or on a plane if you have a phobia of flying.
Does Kaiser Permanente cover therapy?
Kaiser Permanente provides personalized treatment plans for mental health.
These plans typically cover one-on-one therapy with a professional such as a psychiatrist or nurse practitioner who specializes in mental health.
They also cover group therapy sessions and mental health classes.
Personalized stress management and addiction counseling are also included.
There are many places to start your search for a therapist or counselor that you want to work with, from asking people you know to talking with your primary care physician.
Start with the in-network list
If your insurer has a network of providers, this may be a good place to start looking for a therapist. Each therapist listed should have some information about their practice and specialty areas. These may include pediatrics, geriatrics, conditions such as obsessive-compulsive disorder or bipolar disorder, and their approaches to care.
Review lists from organizations for your location
The American Psychiatric Association provides a list of psychiatrists who have opted in to the database by zip code.
The American Psychological Association provides a list of psychologists by zip code.
You can also look for a therapist through the Open Path Psychotherapy Collective. This nonprofit nationwide network offers inexpensive therapeutic options for individuals, couples, and children.
If you intend to pay for therapy out of pocket, know that psychiatrists may charge different rates per hour than other types of mental health professionals, such as psychologists or licensed clinical social workers. This may also affect the cost of your copay, if you use your insurance to pay for therapy.
Paying for care
Understandably, the cost of therapy can be a big concern. Many therapists accept patients on a sliding scale. If you’re concerned about the cost of therapy, ask the therapist you’re considering if they’ll work with you on price or about any payment options they offer.
Most health insurance plans cover some level of therapeutic services. The amount of coverage you can expect will vary from plan to plan. In many instances, you’ll have a deductible to pay before your services are covered. Copays and coinsurance may also apply.
Services such as therapist visits, group therapy, and emergency mental healthcare are typically covered by health insurance plans. Rehabilitative services for addiction are also included.
Therapy can be expensive, with or without insurance. There are low-cost options that can help, such as therapists who take sliding scale payments and psychotherapeutic collectives that offer steeply reduced sessions.
If you need therapy but can’t afford it, talk to your doctor or another professional you trust, such as a clergy member or school guidance counselor. There are many ways that the financial barriers between you and the therapeutic care you need can be removed.