Help me check my health insurance math!
December 3, 2014 7:51 AM   Subscribe

After being recommended multiple therapists and not a single one accepting insurance, I've determined that the only financially advantageous avenue to pay for therapy is to switch to a high deductible insurance plan with a HSA in order to lower my premiums and maximize my tax situation. Is there anything I'm missing or not taking into consideration?

This is all such a nightmare that even after reading all the fine print I still have a sinking feeling I'm missing something.

I would be switching to Aetna Direct high deductible plan for federal employees. It has an in network deductible of $1,500 and out of network $2,500. I would be going to my regular GP and any specialists in network. I am on regular medication, but it is generic and last year without insurance would have cost me $516. This is basically negated by the amount I will save in premiums by switching: $573.24 (under my current plan I pay nothing for generic prescriptions).

Under the Aetna I will have to pay for see my GP until I hit my deductible, which I will need to do at least 2-3 times to refill my prescriptions. My current plan this is free. I believe this will cost me about $500 (obviously this could be off by $100-200).

So the real savings comes from having access to the HSA. The Aetna has a premium pass through to my HSA that amounts to $750 a year. So when I take this into account on top of what I will be saving in premiums by switching, even with the significant out of pocket expenses, I should still be ahead of the game by about $300.

This would not in itself be enough for me to switch because if something happens I'm out the full deductible at a minimum plus the 10% of the cost as opposed to a relatively low fixed copay. However, I have savings and a good job so I am in a situation to absorb this cost if I have to. I am also otherwise young and in good health.

So to the point of the whole thing. I want to start therapy. I have been on antidepressants for 10+ years and I would like to at least explore getting off of. I have previously been diagnosed with double depression and general anxiety disorder. I also have other longstanding personal issues I think I need to deal with. I have found a therapist (LICSW) who specializes in Intensive Short-Term Dynamic Psychotherapy, does not accept insurance and charges $160 an hour.

As far as I can tell getting insurance to pay for out of network therapists is a fool's errand and at most they will pay part of their "allowed amount." My current insurance refuses to tell me what that is in advance and insists I have to submit a bill in order for them to assess it. From what little I can find online it is probably around the $100 a session??? I would have to pay a $70 copay on top of the difference between the allowed amount, meaning my insurance would pay a measly $30 a session and even then only after I met my deductible.

So saving on the taxes seems to be the only real savings to be had. An HSA seems way more attractive than an FSA for a few reasons:

- I don't lose all the money if I end up not using it (if therapy is quickly a bust and it has been before, I could be out $2,000+ with a FSA)
- I (think) I can make deposits whenever I want into the HSA as opposed to having a fixed amount coming out of my paycheck.
- I really only have a vague idea how long I'll go to therapy (it says short right?) so I'm very hesitant to have the maximum coming out of my paycheck as it will be a hit to my income and I don't otherwise have a lot of health expenses
- I believe with an HSA I could theoretically go to therapy, pay out of pocket until I hit the HSA max of $3,350, putting nothing into my HSA during this time and carrying a zero balance. Then I could turn around deposit $3,350 into the account, submit claims for all of the therapy, get paid out for that money and then deduct it on my taxes when I file my tax return. Is my understanding of this correct?
- Also, the HSA has a max of $3,350, which the FSA is $2,550. $2,550 would only get my 16 sessions, which seems a little on the low end, but maybe not?

Is there anything else I am not taking into account? Everything I can find says that therapy is generally a qualified medical expense for an HSA (but say marriage counseling is not), but is this something I am likely to have issues getting reimbursed for? Any thoughts, anecdotes or words of wisdom are welcome.
posted by anonymous to Health & Fitness (5 answers total) 2 users marked this as a favorite
"My current insurance refuses to tell me what that is in advance and insists I have to submit a bill in order for them to assess it. "

Check and see if you have a process to get pre authorization for the treatment. I know some insurance has a process where you can submit all the codes from the doctor and it will go through their system and pre authorize you.
posted by WizKid at 8:05 AM on December 3, 2014 [1 favorite]

Your reasoning seems sound. Only thing I'd ask is whether you've looked into in-network therapists. I did a screen for a friend about a year ago starting with every in-network provider within a 15 minute drive on his insurance's provider list, and then seeing what info I could find on each via a Google crossref. It was a smaller list, and we dropped a quarter of them due to craziness, woo or religious comments in their online presence, but out of the 30 or so we had around five that were promising enough to contact, and the first guy he made an appointment with was a reasonable fit.

The process was time consuming but worthwhile for the cost savings, so if you have time left in open enrollment, I'd consider it.
posted by deludingmyself at 8:28 AM on December 3, 2014

Reimbursements for therapists are usually in the $85-100 range, so that's probably about right.

Have you actually met with the therapist? If not, it may be worth spending $160 out of pocket first to have a session with them to talk about what you'd like to work on and how long they estimate that might take. They likely can't give you a guarantee, but "short-term" can mean anything from two months to twelve months. (The more items you want to address, and the longer-standing those issues, the longer the therapy generally needs to be in order to be effective.) The website for Intensive Short-Term Dynamic Psychotherapy says "usually under 40 hours," which would be 40 weekly sessions.

I'd also want to be really sure I felt I clicked with the therapist before switching my health insurance to work with them. Psychodynamic therapy uses the relationship between the therapist and the client as a huge part of the therapy -- in that the way you relate to the therapist likely mirrors the way you relate to others, so by talking about the relationship between you and the therapist, you can gain insight and make positive changes in your "outside the office" relationships -- so the quality of the relationship is very important.
posted by jaguar at 8:40 AM on December 3, 2014 [1 favorite]

I can't address the therapist side of the question, but just be clear about what you'll be paying on the high-deductible. After the deductible, is there a percentage you'd be paying? My insurance works thus: I pay 100% of everything until I hit my deductible ($1750), then I pay 20% of everything until I hit my out-of-pocket maximum ($4000), after which everything is free. So at most per year I pay $5750 plus my small monthly premiums. So in your math, are you figuring on the out-of-pocket maximum also?
posted by clone boulevard at 8:49 AM on December 3, 2014 [2 favorites]

As far as I can tell getting insurance to pay for out of network therapists is a fool's errand and at most they will pay part of their "allowed amount."

No, your insurance sounds really weird. No therapists seemed to be in-network with my insurance either (United), but they pay 60% once you've hit your deductible. So what happens is, my therapist gives me a statement every so often, I file it electronically through United's website, and they send me a check. I guess it's not ideal (since you do have to "float" the expense for some time), but it's easy and straightforward.
posted by Violet Hour at 9:44 AM on December 3, 2014

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