How does insurance work with therapy?

How to check your insurance benefits

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One of the most frequent questions prospective clients ask is about how insurance works for counseling. It's not too difficult to find out, and if you are on a budget, it's crucial that you understand how it works, before you start with a therapist.  As you think about budget, please know that it's almost always best to be able to come to weekly appointments , rather than less often, at least at first, just to get some momentum going. Once you have your insurance information , you'll be able to figure out which therapists will fit your budget best on a weekly basis.

The two biggest variables are the size of your deductible, and the amount you are responsible for paying yourself. This is going to be directly impacted by whether or not you choose to use a therapist from your insurance company's preferred provider panel, assuming you have PPO and not HMO insurance (EPO is like HMO, by the way, which means no coverage outside the network). With PPO insurance, If you go outside your network you will pay more out of pocket but you can choose from any therapist whether they are contracted with your panel or not.

You may be wondering, why are some therapists on panels, and some are not? There are many therapists (like myself) who do not wish to sign contracts with insurance panels, most often because for various reasons they are able to attract enough clients who are willing to pay their fee, rather than a significantly lower contracted fee. However, there are also many excellent and experienced therapists who are on panels , who don't enjoy the process of marketing their practice and are willing to accept a lower fee as a result.

Ok, back to the finances part, and learning what it's going to cost. The quickest way to sort all this out is to either call your insurance company or go online if you can, and ask these questions:

  1. What is my deductible for in network vs. out of network providers, and how much of either have I met so far this year
  2. What is my in-network co-pay (generally a flat dollar amount), vs my out of-network reimbursement rate (generally a percentage of what the therapist charges) .

When you see someone in-network generally you pay a flat co-pay, assuming your deductible if any has been met . When you see someone out-of-network, you generally pay the therapist, they give you a super bill or otherwise help you bill your insurance (I do this for you automatically, by the way), and your insurance company sends you a check once your out-of-network deductible has been met.

One more thing to keep in mind about insurance. Your medical insurance will only cover services that are "medically necessary". That means your symptoms must meet the level of a diagnosis, and that diagnosis and treatment will then be part of your medical record. Some people like to avoid using insurance for this reason alone.

So the bottom line is that like with so many things, there is a trade off in terms of money vs. range of choice and perhaps privacy. You will generally spend less money by using a panel provider, but you will have fewer choices. If you were referred to a specific therapist, or are looking for one with extensive skills and training in certain areas, there may not be many who are on insurance panels.

I hope this information has been helpful. If you've been referred to Families Counseling in Simi Valley, or if you are in the Simi / Moorpark / Conejo Valley area, please feel free to call me at 805-583-3976, x 33 or e-mail me. I'll be happy to help you sort this out . My pledge for over 20 years of practice has been that I will help you find the best therapist for your situation, in our offices or elsewhere .

Sincerely,

Deborah Tucker, M.A.
Licensed marriage and family therapist
(MFT #17142)
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Families Counseling is owned by Deborah Tucker, MA, LMFT #17142. Each of the practitioners in this office is a sole-proprietor, which means that the professional is in business for himself or herself. Deborah Tucker DBA Families Counseling is not a partnership, a joint venture, a professional corporation, or any other form of business organization with any of the other practitioners in this suite of offices.