Therapy financial questions
December 8, 2023 6:40 AM Subscribe
I’m looking into therapy, because well the last four years have been the longest decade of my life, but we’re changing insurance at work at the first of the year (and of course the deductible resets as well.) I need to complete enrollment, and I also need to have an idea of typical therapy costs and such entail as it can affect which plan I choose.
I’ve seen many therapist pages that list self-pay fees anywhere from $120 or $200 per session. In your experience, how has this worked with your insurance? (I currently have a HSA plan, but I’m considering a PPO plan with higher premiums but co-pays and a lower per person deductible. As it is my insurance is almost prohibitively expensive, so I need to make this work as best as possible.) For those with HMO/PPO plans, did you typically end up paying towards your deductible or did your co-pay cover the visits? For those with HSA plans, what did you typically end up paying per visit? Also, is there a typical schedule, like one session per week or two/three sessions per week, something along those lines? Thanks!
I’ve seen many therapist pages that list self-pay fees anywhere from $120 or $200 per session. In your experience, how has this worked with your insurance? (I currently have a HSA plan, but I’m considering a PPO plan with higher premiums but co-pays and a lower per person deductible. As it is my insurance is almost prohibitively expensive, so I need to make this work as best as possible.) For those with HMO/PPO plans, did you typically end up paying towards your deductible or did your co-pay cover the visits? For those with HSA plans, what did you typically end up paying per visit? Also, is there a typical schedule, like one session per week or two/three sessions per week, something along those lines? Thanks!
My plan went to $0 for virtual visits in 2023 which is a huge savings, worth checking to see the benefits chart in your plan to see if there is any difference for virtual visits and what the actual coverage is for therapy visits (unlimited? certain number per year?).
In Network
Once you know what the coverage is for in-network and out-of-network, then see if you can find in-network available therapists, you can ask them what diagnostic code they would bill - a 60 minute family/individual therapy appointment for example with an actual code, then ask the healthplan provider what they allow for this diagnostic code - say $129 for example. Then you'll know the amount billed per appointment. This likely would be paid out of pocket by you until your deductible is met, then you pay the co-pay for each visit and the healthplan pays the rest.
Out of Network
If your therapist is out-of-network, then they bill you whatever they want and your plan pays whatever they want, you pay the difference. Ask your plan what they pay for out-of-network providers, if anything, for that diagnostic code. My out of network deductible is so high, we have essentially no out of network coverage. If you are charged $200 and the plan pays $75, the you pay the $125 difference per appointment; however, you very well may just pay the out-of-pocket amount.
It is worth asking providers what the per visit amount would be if you don't go through insurance. Laws may be different by state or interpreted differently for cash / check (paid today versus by invoice).
Good luck, this can be challenging to figure out. We spend a lot of time with a spreadsheet and assumptions to choose a plan. Sometimes it is clear but often we are making guesses as to what the best plan is.
posted by RoadScholar at 8:13 AM on December 8, 2023
In Network
Once you know what the coverage is for in-network and out-of-network, then see if you can find in-network available therapists, you can ask them what diagnostic code they would bill - a 60 minute family/individual therapy appointment for example with an actual code, then ask the healthplan provider what they allow for this diagnostic code - say $129 for example. Then you'll know the amount billed per appointment. This likely would be paid out of pocket by you until your deductible is met, then you pay the co-pay for each visit and the healthplan pays the rest.
Out of Network
If your therapist is out-of-network, then they bill you whatever they want and your plan pays whatever they want, you pay the difference. Ask your plan what they pay for out-of-network providers, if anything, for that diagnostic code. My out of network deductible is so high, we have essentially no out of network coverage. If you are charged $200 and the plan pays $75, the you pay the $125 difference per appointment; however, you very well may just pay the out-of-pocket amount.
It is worth asking providers what the per visit amount would be if you don't go through insurance. Laws may be different by state or interpreted differently for cash / check (paid today versus by invoice).
Good luck, this can be challenging to figure out. We spend a lot of time with a spreadsheet and assumptions to choose a plan. Sometimes it is clear but often we are making guesses as to what the best plan is.
posted by RoadScholar at 8:13 AM on December 8, 2023
I should clarify. The cost of virtual visits, therapy or otherwise, in my plan is $0 for me just like annual physicals whereas in-person visits would cost around $100.
posted by RoadScholar at 8:23 AM on December 8, 2023
posted by RoadScholar at 8:23 AM on December 8, 2023
I have usually seen therapists weekly.
My insurance theoretically has providers that are in network but the overlap between "providers on my plan" and "providers recommended to me" always seems to be zero. So I go to someone who doesn't bill insurance.
With my current insurance, I pay cash to my therapist ($150 per session, but $135 each if I pay for 10 up front). She sends me an invoice every 2-3 months and I upload that to my insurance website, and they send me a check. I do have a deductible at the beginning of the year.
posted by radioamy at 10:38 AM on December 8, 2023
My insurance theoretically has providers that are in network but the overlap between "providers on my plan" and "providers recommended to me" always seems to be zero. So I go to someone who doesn't bill insurance.
With my current insurance, I pay cash to my therapist ($150 per session, but $135 each if I pay for 10 up front). She sends me an invoice every 2-3 months and I upload that to my insurance website, and they send me a check. I do have a deductible at the beginning of the year.
posted by radioamy at 10:38 AM on December 8, 2023
Best answer: I'm a therapist. Here's what I would recommend:
For each insurance company, search Psychology Today for in-network therapists near you and see who turns up (if you're open to telehealth, you can cast a wide net). Are there a lot of providers? How many have "waitlist only" or "not accepting new clients" on their profile? Can you find therapists who offer the types of services you're looking for, or who appeal to you?
With the data from PT searches, look at the in-network outpatient mental health coverage in the plans your employer offers. If there are a lot of therapists in your area who are in-network with Cigna, look at the Cigna plan(s) offered by your employer. One might have a copay of $30 per session; another might require you to pay the therapist's contracted rate until you meet your deductible, then cover sessions in full. But remember: the contracted rate is going to be lower than the private pay rate. In other words, if Sue Smith, LCSW is in-network with Cigna, she might have a private rate of $160 but a contracted rate with Cigna of $100, so you'd pay $100 per session until you met your deductible.
Additionally, for each plan your employer offers, look up the out of network (OON) benefits. How high is the deductible you have to meet before your OON coverage applies, and are you likely to meet it? How much does the plan cover per session with an OON provider? Some plans offer more generous coverage (e.g., 80% of the fee), while others are more like a slight discount (e.g., $25 per session). If there's a plan that has really great OON benefits, I'd go that route. That would allow you to choose any therapist you like. You pay their private fee up front when you meet, they generate a superbill for the session, you send the superbill to your insurance, insurance sends you a check for the allowed amount, and you reimburse yourself any remainder out of your HSA. (So, for instance, you pay your therapist $160 for the session, insurance sends you a check for $128, and you reimburse yourself $32 out of your HSA.)
Finally, it's also worth looking at the larger therapy practices in your area. Because they have the resources for support staff to do the billing and scheduling, they can be the easiest way to use your insurance for therapy. The trade-off is that you generally get assigned to whoever is available and may have to change clinicians if you don't feel like it's a good match.
This is a weird time for finding a therapist who takes insurance. On the one hand, there are some tech companies that are making it easier for private practice therapists to get contracted with insurance companies (something a lot of newer therapists are doing), but on the other hand, taking insurance can be a real headache for private practice therapists (low rates, delayed payments, clawbacks, denied or lost claims, audits). This isn't a plea for sympathy, just some context to be aware of. If you're open to working with an early-career therapist or going to a larger group therapy practice, you may have an easier time finding someone who takes your insurance. If you really want to prioritize finding someone who's the best fit for you, look into the OON options first.
posted by theotherdurassister at 1:26 PM on December 8, 2023
For each insurance company, search Psychology Today for in-network therapists near you and see who turns up (if you're open to telehealth, you can cast a wide net). Are there a lot of providers? How many have "waitlist only" or "not accepting new clients" on their profile? Can you find therapists who offer the types of services you're looking for, or who appeal to you?
With the data from PT searches, look at the in-network outpatient mental health coverage in the plans your employer offers. If there are a lot of therapists in your area who are in-network with Cigna, look at the Cigna plan(s) offered by your employer. One might have a copay of $30 per session; another might require you to pay the therapist's contracted rate until you meet your deductible, then cover sessions in full. But remember: the contracted rate is going to be lower than the private pay rate. In other words, if Sue Smith, LCSW is in-network with Cigna, she might have a private rate of $160 but a contracted rate with Cigna of $100, so you'd pay $100 per session until you met your deductible.
Additionally, for each plan your employer offers, look up the out of network (OON) benefits. How high is the deductible you have to meet before your OON coverage applies, and are you likely to meet it? How much does the plan cover per session with an OON provider? Some plans offer more generous coverage (e.g., 80% of the fee), while others are more like a slight discount (e.g., $25 per session). If there's a plan that has really great OON benefits, I'd go that route. That would allow you to choose any therapist you like. You pay their private fee up front when you meet, they generate a superbill for the session, you send the superbill to your insurance, insurance sends you a check for the allowed amount, and you reimburse yourself any remainder out of your HSA. (So, for instance, you pay your therapist $160 for the session, insurance sends you a check for $128, and you reimburse yourself $32 out of your HSA.)
Finally, it's also worth looking at the larger therapy practices in your area. Because they have the resources for support staff to do the billing and scheduling, they can be the easiest way to use your insurance for therapy. The trade-off is that you generally get assigned to whoever is available and may have to change clinicians if you don't feel like it's a good match.
This is a weird time for finding a therapist who takes insurance. On the one hand, there are some tech companies that are making it easier for private practice therapists to get contracted with insurance companies (something a lot of newer therapists are doing), but on the other hand, taking insurance can be a real headache for private practice therapists (low rates, delayed payments, clawbacks, denied or lost claims, audits). This isn't a plea for sympathy, just some context to be aware of. If you're open to working with an early-career therapist or going to a larger group therapy practice, you may have an easier time finding someone who takes your insurance. If you really want to prioritize finding someone who's the best fit for you, look into the OON options first.
posted by theotherdurassister at 1:26 PM on December 8, 2023
Another variable is duration of treatment. I have been in and out of therapy for decades, and I have never stayed on weekly sessions with a therapist for longer than six months. I get therapy fatigue. At that point I might go to a lower frequency or put therapy on pause.
Also, there is a chance you will not be a match with your therapist, so you might have to do the first few visits with 2-3 providers until you make a match.
Groups are another way to change your cost model. DBT and CBT often have groups that can be done in addition to or instead of individual therapy. Something to consider.
posted by shock muppet at 3:42 PM on December 8, 2023
Also, there is a chance you will not be a match with your therapist, so you might have to do the first few visits with 2-3 providers until you make a match.
Groups are another way to change your cost model. DBT and CBT often have groups that can be done in addition to or instead of individual therapy. Something to consider.
posted by shock muppet at 3:42 PM on December 8, 2023
I would check to see if any plans cover a telehealth service like MDLive.
My copay is $0 if I do virtual therapy via my telehealth service.
posted by champers at 3:58 AM on December 9, 2023
My copay is $0 if I do virtual therapy via my telehealth service.
posted by champers at 3:58 AM on December 9, 2023
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in terms of schedule, that is really up to you and your therapist. i have usually gone once a week, and dropped down to once a month when i felt i was doing okay. depending on you and your issues, you may start out by going more frequently.
you should also pick a couple therapists and see if they even accept your current insurance, or will accept the one you're thinking of switching to. i personally have found better coverage by having a PPO than an HDHP, HSA, or HMO.
posted by misanthropicsarah at 6:54 AM on December 8, 2023