How to check your mental health insurance benefits
To check your mental health benefits, call the member services number on your insurance card and ask five things: whether you have mental health coverage, where your deductible stands, what your copay per session will be, how many sessions are covered each year, and whether you need approval before you start.
Key points
Call the member number on your insurance card before your first appointment.
Ask about your deductible, copay or coinsurance, session limits and approvals.
Confirm the specific clinician is in your plan's network.
Write down the date, the representative's name and a reference number.
If coverage falls short, self-pay rates and a Sliding Fee Program are available.
How do you find out if your insurance covers therapy?
The only reliable answer comes from your own plan. Two people with the same insurance company can have very different benefits, because coverage depends on the plan an employer or individual chose.
Turn your insurance card over and call the member services number. If the card lists a separate number for behavioral or mental health, use that one. Have your member ID ready, and have a pen. Your plan's website or app may show the same details if you prefer not to call.
If you bought your plan through the Health Insurance Marketplace, one thing is settled already. HealthCare.gov states that all Marketplace plans cover mental health and substance abuse services as essential health benefits, including outpatient therapy and counseling. What you pay for each visit still depends on your plan.
What questions should you ask your insurance company?
These steps build on the five questions our practice suggests to new patients. Ask them in order and write down each answer.
Do I have mental health benefits?. Ask specifically about outpatient therapy, and whether telehealth sessions are covered the same way as office visits.
What is my deductible, and how much have I met?. Ask for the amount met so far this plan year and the date the deductible resets.
What will I pay for each session?. Your share may be a copay, coinsurance, or the full allowed amount until the deductible is met. Ask which applies to outpatient mental health visits.
How many sessions per year are covered?. Ask whether there is a visit limit, and what happens if you and your therapist think more sessions are needed.
Do I need approval first?. Ask whether the plan requires a referral from your primary care physician or prior authorization before therapy begins.
Is this clinician in my network?. Give the practice name and the clinician's name and license type. Ask what you would pay if the clinician is out of network.
Get it in writing if you can. Note the date, the representative's name and a call reference number. Ask where the benefit is described in your plan documents.
What do deductible, copay and coinsurance mean?
Insurance language makes more sense once you know five terms. The definitions here follow the HealthCare.gov glossary.
Deductible: the amount you pay for covered health care services before your plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
Copayment, or copay: a fixed amount, such as $20, that you pay for a covered service after you have paid your deductible.
Coinsurance: a percentage of the cost of a covered service that you pay after you have paid your deductible. The plan pays the rest.
In-network: a provider is in network when your insurer or plan has contracted with them to provide services. The network is the full set of those facilities, providers and suppliers.
Prior authorization: a decision by your insurer that a service is medically necessary, which some plans require before you receive certain services. It is also called preauthorization or precertification.
Good to know about prior authorization
HealthCare.gov notes that preauthorization is not a promise that your plan will cover the cost. Ask the representative what else has to happen for a claim to be paid.
Can a plan limit mental health coverage more than medical care?
For Marketplace plans, HealthCare.gov describes parity protections. In general, the limits a plan applies to mental health and substance abuse services cannot be more restrictive than the limits it applies to medical and surgical services.
Those protections cover three kinds of limits: financial ones, such as deductibles, copayments, coinsurance and out-of-pocket maximums; treatment limits, such as caps on the number of covered visits; and care management rules, such as having to get authorization before treatment.
Marketplace plans also cannot deny you coverage or charge you more because of a pre-existing condition, and that includes mental health conditions. If an answer from your plan seems out of line with this, ask the representative to point you to the written policy.
Which insurance plans does Balanced Life accept?
We accept the plans listed below. Being on the list does not mean every plan from that company covers every service, so please verify your own benefits.
CareFirst / Blue Cross Blue Shield
Cigna
Claimsbridge
Core Source
Humana
Integra Administrative Group
Medical Assistance / Medicaid
Medicare
Tricare
UMR
United Behavioral Health / UnitedHealthcare
What if you do not have insurance or would rather not use it?
You can pay for therapy yourself. Our self-pay fees are $150 for an initial assessment, $130 for individual therapy of 45 to 50 minutes, $65 for a 30-minute session, $130 for family therapy and $35 for group therapy. We accept cash, check and credit cards.
We also offer a Sliding Fee Program based on household income and family size. It may reduce the amount you pay for services, even if you have insurance. The application asks for identification or proof of address and proof of income, and is completed every 12 months, or sooner if your financial situation changes.
If you plan to pay yourself, our article on good faith estimates and our No Surprises Act page explain the cost information you can ask for in advance.
How Balanced Life can help
Our insurance and fees page has the full plan list, self-pay rates and the Sliding Fee Program application. Once you know your benefits, our new patient page explains how to schedule individual counseling or family therapy in Salisbury, in Bethesda or by telehealth.
Sorting out coverage should never delay urgent help. If you are in crisis, call or text 988 or call 911. Our office does not provide emergency services.
Frequently asked questions
What is the difference between a copay and coinsurance?
A copay is a fixed dollar amount you pay for a covered service, such as a set fee per therapy visit. Coinsurance is a percentage of the cost of the service. In the HealthCare.gov definitions, both apply after you have paid your deductible. Your plan documents show which one applies to outpatient mental health visits.
Do I have to meet my deductible before insurance pays for therapy?
It depends on the plan. A deductible is the amount you pay for covered services before the plan starts to pay, but plans handle office visits differently. Ask your insurer whether outpatient mental health visits are subject to the deductible, how much you have met so far, and what you will owe per session until then.
Does prior authorization mean my therapy is covered?
No. Prior authorization, also called preauthorization, is a decision by your insurer that a service is medically necessary. HealthCare.gov states that it is not a promise your plan will cover the cost. Ask your plan whether outpatient therapy needs authorization at all, and what other conditions apply.
Can I use the Sliding Fee Program if I have insurance?
Yes. Our Sliding Fee Program is based on household income and family size, and it may reduce the amount you pay for services even if you have insurance. You complete an application with proof of income and identification or proof of address. Ask our office for the form or find it on our fees page.
What if I miss or cancel a therapy appointment?
Please let us know at least 24 hours in advance if you cannot keep your appointment. With less notice, you may be required to pay a missed appointment fee. If you are unsure how a late cancellation would be handled, ask our office when you schedule, before it comes up.
Sources
If you are in crisis or thinking about suicide, call or text 988 (Suicide and Crisis Lifeline). In an emergency, call 911.