What To Ask Your Health Insurance Company To Check Therapy Benefits

If you are looking to use your health insurance to pay for therapy sessions, the first step is to learn what your insurance benefits cover. Many health insurances — particularly PPO plans — have great coverage, paying for the majority of your therapy session. Others — such as HMO plans — are more limited in coverage.

Get started by calling your health insurance company and asking the following questions. You can typically find your insurance company's phone number on the back of your insurance card, or by searching for it online.

Information to prepare prior to calling

Before you make the call, here is some information that will make your call go smoother and allow you to gather comprehensive details around your coverage. You can ask the therapist you are considering for this information when you have an initial call with them as well.

Provider's full name: Make sure to ask your provider for their full registered name. For example, while they may go by "Dr. Jess," their full name in the healthcare system may be "Jessica Jones."
Provider's NPI: Every licensed therapist has a National Provider Identification. You can ask your therapist for this on your initial call.
Health insurance card: Have your health insurance card handy so you have the insurance company's phone number, your Member ID number, and any other plan details you may be asked for.
Full name and date of birth of the subscriber: If you are on your parents' or spouse's health insurance plan, you may want to have their name and DOB prepared and ready to provide.
(Nice to have) CPT Codes: CPT stands for Current Procedural Terminology and refers to the type of treatment you are receiving. Ask your provider for which CPT codes you should provide. For example, 90791 for the intake appointment (Psychiatric/psychological diagnostic interview without medical services) or 90834 for ongoing therapy sessions (Individual psychotherapy, 45 minutes).

Call the phone number for your health insurance company's Member Services. You may find this on the front or back of your insurance card.

Follow prompts to "Check Eligibility and Benefits" so that you get connected with the right representative.

Questions to ask your health insurance

When calling your health insurance company, it's important to find out a few things, such as your deductible amount, your copay or coinsurance amount, any special requirements to receiving coverage (e.g. referral from a primary care physician), and logistics (e.g. submitting claims for reimbursement).

The questions below will help you gather each of these data points! We recommend asking these questions, jotting down the answers, and sharing them with your therapist who can help you understand what each of these mean.

Questions about in-network benefits

If your therapist says they are "in-network with" or "paneled" with your health insurance, ask your health insurance company the following questions to verify that (1) you indeed can see them in-network, and (2) how much it would cost to see this provider:

Is this provider (full name and NPI) in-network with my health insurance? (Your therapist may not be in-network with your particular plan, so this is important to check!)
What is my in-network deductible for outpatient mental health visits?
How much of my deductible has been met?
What is my copay for outpatient mental health visits?
Is this coverage applicable before or after I meet my deductible?

Questions about out-of-network benefits

If your therapist says they do not take your health insurance, ask your health insurance company the following questions to understand how much of sessions they will reimburse:

What is my out-of-network deductible for outpatient mental health visits?
How much of my deductible has been met this year?
What is my out-of-network coinsurance for outpatient mental health visits?
Do I need a referral from an in-network provider or a primary care physician to see someone out-of-network?
How do I submit claims for out-of-network reimbursement?

Questions about teletherapy

Are virtual outpatient mental health visits (or teletherapy) covered by my plan?

Jot down or type up the answers that the health insurance company shares with you. Send it to your therapist or share it with them over a phone call so that they can help you understand how much therapy sessions with them will cost.

What happens after your therapy session

Pay the therapist's fee or your copay / coinsurance

At each therapy session, you will either pay the therapist's full fee (typically the case if you are seeing an out-of-network provider) or your copay amount (this is typically the case if you are seeing an in-network provider). There are two possible scenarios in regards to what fees you can expect to pay at your session:

Scenario 1: Your insurance plan requires you to meet your in-network deductible before your copay applies. Meaning, you need to meet your deductible before you only pay your copay at your appointment. To meet your deductible, you could expect to pay your full session fee. You can also meet your deductible by paying for other medical expenses such as prescriptions or medical services — these will all contribute to meeting your deductible.

Scenario 2: You only pay your copayment fee before a therapy session. You do not need to meet your deductible, and so you would not need to pay the full session fee.

To learn more about what fees you can expect to pay before a session with a therapist, and if you need to meet your deductible first, speak with your insurance provider.

Submit a claim to receive out-of-network reimbursement

If you are seeing an out-of-network therapist, your therapist will typically send you a superbill on a monthly or more frequent basis. This is like a receipt or invoice for all of your sessions that also indicates the diagnostic code you can use to submit claims to your insurance company for reimbursement. You can then mail this to your insurance company (typically via snail mail but some insurances offer an online portal or email option as well. You can also use a tool like Reimbursify to facilitate this electronically) and receive the reimbursable amount via check. Some therapists offer the option to submit these claims on your behalf to the insurance company directly as well. While fee and insurance-related questions can be cumbersome to deal with, you have a lot to potentially gain from understanding your benefits well. Don't be shy to ask your therapist to help you understand how it all works — that's part of their job, too!