Step-by-Step Guide to Out-of-Network Benefits

by Yuri Tomikawa, Maggie Jordan

When looking for a therapist, you have the option to choose between in-network and out-of-network providers. In-network therapists are called “in-network” because they have negotiated a contracted rate with your health insurance company; as a result, they are typically more affordable than out-of-network therapists.

While finding an in-network therapist is often the default choice, checking out out-of-network therapists can help expand your therapist search. This is especially true in big cities like New York City, Boston, and San Francisco, where therapists who take insurance tend to be booked out to full capacity and have long wait times for appointments.

If the therapist you’re seeing is not in-network with your insurance, then you will have to pay the full price of the session upfront. Fortunately, depending on your health insurance plan, your insurance company may help reimburse a portion of the cost by mailing you a check or depositing money into your account. If you have a PPO or POS health insurance plan, you’ll get back partial reimbursement for out-of-network services, making seeing an out-of-network therapist more cost-effective and budget-friendly.

Still unsure about using your out-of-network benefits? Use the following steps to learn how out-of-network benefits work and how you can work with an out-of-network therapist. We’ll also talk about how to get an out-of-network reimbursement paid. Though navigating out-of-network benefits can be cumbersome, it can save you a lot of money in the long run. Even if you don’t fully understand the terms below, having the details upfront can help you figure out how payment works, and prevent any unexpected bills.

1. Check your out-of-network benefits

These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:

  • Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement.

Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”

In this scenario, if you spend $1,500 on therapy services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but a portion of the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim). Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.

  • Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.

Let’s say your therapist charges $100 per session. If your coinsurance is 25%, you’re only responsible for paying $25. Just remember that this comes in the form of a reimbursement: you’ll need to pay the full $100 upfront, then your insurance will send you a check for $75 after the session, once you’ve met the deductible and submitted a claim.

Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are. In other words, if your insurance has an allowed amount of $100 but your therapist’s session fees are $200 per session, you won’t get reimbursed more; you’ll still be reimbursed $75, and will be ultimately responsible for $125.

2. Call your insurance company to verify your benefits

1. Check your out-of-network benefits

These are typically in the Summary of Benefits document, which is included in a member information packet or on your insurance company website. Keep an eye out for these terms:

  • Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement. One you hit this amount, then you can access your out-of-network benefits.

Let’s say your out-of-network deductible is $1,000, and your insurance company pays 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.” and can start to access your out-of-network benefits.

In this scenario, if you spend $1,500 on therapy services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but a portion of the remaining $500 will be reimbursed to you in the form of a check (mailed to you or deposited into your account after you submit your claim). Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.

  • Coinsurance: This is the percentage of the service fee that you’re ultimately responsible for paying.

Let’s say your therapist charges $100 per session. If your coinsurance is 25%, you’re only responsible for paying $25. Just remember that this comes in the form of a reimbursement: you’ll need to pay the full $100 upfront, then your insurance will pay you $75 after the session, once you’ve met the deductible and submitted a claim.

Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are. In other words, if your insurance has an allowed amount of $100 but your therapist’s session fees are $200 per session, you won’t get reimbursed more; you’ll still be reimbursed $75 and will be ultimately responsible for $125.

2. Call your insurance company to verify your benefits

The best way to be sure of your benefits is to clarify information with your insurance company member services line. You can find this phone number on the back of your insurance card or through your online insurance platform.

Ask these questions when speaking to your insurance company about benefits:

  • How much of my deductible has been met this year?
  • What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital such as therapy sessions.)
  • What is my out-of-network coinsurance for outpatient mental health?
  • Do I need a referral from an in-network provider to see someone out-of-network?
  • How do I submit claim forms for out-of-network reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)

3. Ask your therapist for a Superbill

When you’re looking for a therapist, ask if they are willing to submit claims to your insurance company for reimbursement. While some therapists offer this, typically, the client is responsible for submitting claims (learn more about different billing options here.)

Your therapist will provide you with a document called a Superbill that you send directly to your insurance company at the end of each month. The Superbill details how many sessions you’ve had, and the total fee.

4. Receive out-of-network reimbursement!

You’ll need to pay your therapist the entire session fee at the time of service, but depending on your specific plan, your insurance company will mail you a check to reimburse a portion of that cost. There are even apps for that! Using an app like Reimbursify can help you navigate the reimbursement process in a few clicks.

There are many reasons to see an out-of-network therapist. By following these steps, you’ll be able to expand your search and make the most of your insurance. Now that you have the details, dare to dream big as you search for the perfect therapist for you. Zencare makes it simple to learn more about the therapists in your community through our therapist directory, where you can view therapist introductory videos, read about their approaches, and book a consultation call with them all from their profile page. You’ll also find information about their accepted insurance and fees, but remember that seeing an out-of-network therapist is worth considering.