Out-of-Network Benefits Guide

How to Navigate Your OON Benefits With Your Insurance & Why Going OON Benefits You

You can see if you have OON coverage by logging into your insurance company website or calling the number on the back of your card.

Here is a step-by-step guide with a list of questions to ask:

  1. Check your Out-of-Network Benefits

    • These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:

      • Out-of-network deductible: This is the amount of money you have to pay before you are eligible for reimbursement.

      • Coinsurnace: This is the percentage of the service fee that you’re ultimately responsible for paying.

      • Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover.

  2. Call Your Insurance Company to Verify Your Benefits

    • The best way to be absolutely sure of your benefits is to clarify with your insurance company. You can find this phone number on the back of your insurance card or through your insurance website.

      Ask these questions when speaking to your insurance company about benefits:

      • How much of my deductible has been met this year?

      • What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital.)

      • What is my out-of-network coinsurance for outpatient mental health?

      • Do I need a referral from an in-network provider to see someone out-of-network?

      • Does my plan reimburse for therapy sessions provided by a Licensed Creative Arts Therapist (LCAT)?

      • How many sessions per year does my health insurance cover?

      • What percentage of the psychotherapy services fee will be reimbursed to me?

      • How do I submit claim forms for reimbursement? (Claims are forms that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket. These typically are called “superbills” which I provide.)

  3. Ask your Therapist for a Superbill

    • As a therapist I provide insurance reimbursement claims for you to give directly to your insurance company for reimbursement. This typically is sent directly to your insurance company at the end of the month via email provided to you by your insurance. The Superbill details how many sessions you have had, and the total fee.

    • This will allow for you to request reimbursement from your insurance carrier if applicable. This process means that you will first pay the cost of the session in full and then submit the receipt provided to your insurance for reimbursement. I will guide you through this whole process and help you come to the best practice with your comfort in mind.

  4. Receive Your Out-of-Network Reimbursement!

    • You’ll need to pay your therapist the entire session fee at the time of service, but depending on your specific plan, your insurance company will mail you a check or a preferred method discussed with your insurance, to reimburse a portion of that cost.

*I have also partnered with Reimbursify for you to easily submit your claims for out-of-network health insurance reimbursement.

Why Should I See A Therapist Out-of-Network?

  • If you are interested in working with a therapist to address a specific challenge, you should consider looking out-of-network.

    Private pay therapists have more specialized practices, and can better address your specific needs through a targeted and effecitve approach without the noise of clinics.

    When you go private pay you are working directly with the therapist, no frustrating middle men and front desk mishaps. Often when we go through insurance and into the clinic we get paired with whoever is available, regardless if its the best fit for us.

    Going OON puts you in control of your care so you can find a therapist that better suits your needs and comfortability.

  • A deductible is the amount you have to pay upfront before your insurance coverage begins.

    For example:

    Say you have a $6,000 deductible and you haven’t had any other medical expenses yet in the year, you are responsible for paying up to $6,000 in therapy session fees out-of-pocket before your standard copay applies. This is a case where seeing an in-network therapist and out-of-network therapist are effectively the same cost. It can also help you meet your deductible quicker so you can use your insurance for your other healthcare needs.

  • If you have good out-of-network benefits, your insurance company may reimburse you as much as up to 80% or the full rate of each session fee, depending on your plan and the therapist’s rate.

    This means that in some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard copay to see an in-network therapist.

  • When a therapist isn’t constrained by only providing services that are billable to insurance companies this opens up more time, creativity, and space to craft the perfect treatment plan for you and your needs.

    This is especially beneficial if you are looking for long term mental health care services. The lack of constraints may benefit your progress as treatment can be more flexible to your ongoing life needs. This means you aren’t stuck in one type of treatment. We can move from CBT to Somatic Art Therapy, or combine the two without conflict of insurance. This leads to better overall care.

    OON Therapist can also offer longer or more frequent sessions than insurance will cover. Say you are going through something and need more support thant 1x a week, such as a time experiencing grief, or a disruptive event. OON therapy can better meet your needs.

    This is also true of services that are not intended to address a diagnosable mental health condition, such as couples therapy, and highly sensitive persons.

  • Some psychiatrists offer both psychotherapy and medication management. However in cases where they do not do so, or are not specialized in your specific needs, you can seek out a therapist that specializes in your needs while recieving medication management.

    This allows for a more comprehensive and highly coordinated care as your therapist and psychiatrist can work together or seperately based on your comfortability.

  • Everyone has the right to privacy.

    Privacy from Family and Employer

    In the case of being on your parents or work insurance plan, you may be uncomfortable with them knowing you see a therapist. In this case you may consider paying out of pocket.

    Privacy from your Health Insurance Company

    In order for your insurance to pay for therapy sessions, therapists are required to provide the company information regarding your sessions. This does not include sensitive information or content of the session but includes a diagnostic code.

    If you don’t want your insurance company to have access to any information about your mental health, you may consider out-of-network options.

  • Due to the high volume of people using their insurance with therapist. It may be difficult to find a therapist with availability as the insurance based practices fill up quickly.

    It can be very difficult to find a therapist in-network and accepting new clients. Most times you will end up on a waitlist for months.

    Because you are working directly with the therapist, they have more availability and flexibility to meet you where you’re at in a quicker time frame.

  • Your relationship with your therapist is one of the most important aspects of the healing process.

    If you only consider in-network therapists, you might not consider therapists who would be a really good fit for you and maybe help you heal and feel better more effectively.

    Settling with an in-network therapist who doesn’t make you feel comfortable or does not specialize in the areas you’re struggling with only because they’re in-network is a waste of money and time.

    Investing in a therapist where you feel aligned with on a personal level and is a great match is important.

    Don’t let insurance dictate your care.

    Your mental health is worth it.

Back to You.
 
 

Insurance Terminology 101

  • Open Enrollment

    Annual period where individuals and employees are able to choose or make changes to their health plan.

  • In- Network

    Healthcare provider is contracted with the insurance company, agrees to charge the client according to their benefits, and will be reimbursed according to the agreed upon allowance.

  • Out-of-Network

    Provider is not contracted with the insurance companies and can charge the full rate. Client’s benefits aren’t guaranteed.

  • Individual Plans

    Purchased directly from the insurance marketplace and payments are made to the insurance company.

  • Employer-Sponsered Plans

    Enrolled in with your or a family member’s employer.

  • Policy Holder

    Employee/person responsible for enrolling in plan.

  • Dependant

    Family member of policy holder (spouse, child, etc).

  • Payer

    Common term for insurance companies.

  • Allowance

    How much a payer agrees to cover of the total cost of care.

  • Write Off

    Difference between the total cost of care and the allowance.

  • Co-Pay

    Fixed amount paid by the client directly to the healthcare provider.

  • Deductible

    Specific amount of money the client must pay before insurance covers any of the cost

  • Coinsurance

    Percentage of allowance that the client pays to the healthcare provider. For example, client owes 20% and insurance covers the other 80%.

  • Health Savings Account (HSA)

    Like a debit card with pre-taxed earnings to go towards qualifying care-related expenses.

  • Flexible Spending Account (FSA)

    Like an HSA but owned by client’s employer.