Insurance and Mental Health

This post will probably end up being Part 1 in a series, since it is definitely information that people need to know. As my followers are aware, I’ve been writing about various mental health topics to help people who aren’t professionals understand psychology, therapy, evaluations, and other topics related to mental health.

I would like to talk today about insurance and therapy. These issues will be specific to the United States, as that is where I practice. Fortunately, most health insurance plans now cover mental health, but the specifics of that coverage varies based on your plan. Typically, therapy sessions are covered in the same way as an office visit with your primary medical doctor, so if you pay a co-pay at that office, you will probably owe the same co-pay for your therapy appointments. If you have a deductible plan, your therapy sessions will apply to that deductible until it is met. At the end of the calendar year, your deductible starts over.

Therapist rates vary, and in Sioux Falls, South Dakota, where I practice, sessions typically bill between $125 to $160 per session. However, if the provider is paneled with your insurance (basically, the insurance company has decided that the provider is “in network” and can bill to your plan), they have a negotiated rate, which can vary significantly. Some insurances I’m paneled with have a negotiated rate of $80, and some have a negotiated rate of $130. So if you are paying for sessions out of your deductible but you change providers, it might look like my rate changed because the negotiated rate with your new insurance company is different than the previous company. It might also look like the rate went up if you switch from a co-pay plan to a deductible plan – if your copay was $40 but the negotiated rate is $100, suddenly what you pay per session more than doubles!

When signing up for therapy services, ask the provider what their per-session rate is, and if they are in-network, you can ask your insurance provider what the negotiated rate is to get an idea of what sessions will cost you.

Most therapists use one of the following billing codes and have unique rates for each:

1. 90837: This refers to a one-hour therapy appointment and is billable for a session lasting 53 minutes or longer. Some insurances will not accept 90837, so make sure that what your therapist bills is covered in your plan.
2. 90834: This is for a traditional 45 minute session and can be billed for sessions lasting 38 minutes to 52 minutes.
3. 90832: This refers to a 30 minute session and is billable for an appointment lasting between 16 and 37 minutes. I use this code sometimes with young kids who can’t engage for a full 45 minutes or if someone arrives late but still wants to meet during the time remaining.
4. 90847: This code indicates family therapy, so I sometimes use it when meeting with the parent and child together to work on their relationship. Some therapists will use this for couple’s therapy, but some insurers specify that family therapy does not include couple’s work, so you will want to ask your insurance carrier if this applies to you.

I also recommend asking your insurance provider if there are any diagnoses that they do not cover. For example, some insurance will not cover therapy if the primary diagnosis is an “adjustment disorder” because that is not considered “severe enough” for treatment to be “medically necessary.” I am not going to say more about that because it makes me too angry to be coherent, but it is information you need to know.

Please know that your therapist has no control over what your insurance carrier covers or does not cover. Insurance companies have a standard line that they say whenever you call them: “Confirmation of coverage is not a guarantee of payment.” This is a fancy way of saying that your insurance can tell your therapist, “Yes, that code is covered!” and then refuse to pay, and there is nothing your therapist can do about it. And once something is billed to your deductible, your therapist has to bill you the remaining balance determined by the insurance company. We can offer flexible payment plans, but we are legally bound by our contract with the insurance company.

If you gain nothing else from reading this post, know that the headache that comes with paying for therapy is at least 95% because insurance is annoying.

What do you wish you knew about the cost of therapy services? Contact me and I will try to explain it!