This is part three of a series about navigating insurance while searching for a therapist. You can start from the beginning here, and check out ways to find an in-network therapist here.

With a PPO or other kind of plan that offers out of network coverage, you have the choice to see in-network or out-of-network providers and get some help from insurance either way. If you choose an in-network provider, you’ll pay only a copay for your visits, just like a regular doctor’s office visit. If you choose an out-of-network provider the process is a bit different.

Check your benefits information online or in the welcome packet you received when you signed up, or call the customer service for your plan, usually located on the back of your id card. You’ll need answers to the following questions to determine how your benefits work and what portion of payment you’ll be responsible for if you see an out of network therapist.

Things to ask customer service:

• Do I have out-of-network coverage for mental health/behavioral health? (If yes, continue. If no, see the post on finding an in-network therapist.)
• What is my deductible? How much of that deductible has been met for this year?
• When does my deductible reset? (e.g. Jan 1st or some other date?)
• What is my coinsurance to see an out-of-network provider?
• Are there any limits to the number of covered outpatient mental health visits in the year?
• What is the maximum allowable fee for a psychotherapy session (CPT code 90834 for individuals or 90847 for couples in most cases)?

Most insurance plans incentivize you to stay in their network by providing more generous benefits for seeing those providers. If you choose someone outside the network, you may be responsible for a deductible, which can vary widely from plan to plan. If you have a very high deductible, it may mean you’ll be expected to pay for all of your therapy out of pocket. Other plans may have small deductibles that will be used up in the first few sessions. Be aware, the rate that your insurance considers you to have paid down your deductible depends on their maximum allowable fee (sometimes called the usual and customary fee), not the amount your therapist bills you. If you have a very high deductible, it may be worth considering negotiating a self pay fee with your therapist rather than using your insurance and/or changing your insurance plan. More on this in a later post.

Once you have tracked down the above information from your insurer, you can calculate your likely out of pocket cost for therapy. That out of pocket cost depends on a few factors; your therapist will have his or her set rate, which may or may not be negotiable based on your financial situation. Your insurance plan will have their own set fee, the maximum allowable fee, that they will cover for a session. Your plan may also have a coinsurance – a percentage of the allowable rate that you are expected to cover each session. This works like a copay for in-network visits, but the amount is expressed as a percentage of the insurance-allowed expense rather than a flat fee. Finally, you’ll have the balance between the insurance payment + your copayment and the your therapist’s total fee. For example:

Your therapist charges $150 per session. You pay her and submit to your insurance plan for reimbursement. Their maximum allowable fee for your visit is $100, and you are responsible for a coinsurance of 20%. They will reimburse you $80, leaving you paying $70 out of pocket.

As you can see, choosing an out of network therapist can cost significantly more than a copay for an in-network person, but may be significantly less than paying the full fee on your own.

Why choose an out of network therapist then? Expertise, convenience, choice

Despite the higher cost, an out of network clinician might be the right choice for you if your needs aren’t a good match with the available in-network clinicians.

• Perhaps you want someone who has experience and expertise in a specific issue, treatment modality, or population that isn’t available in your network.
• Maybe you have a tight schedule and require an appointment during specific hours. Early morning, evening after 5pm, and weekend hours are in high demand and tend to fill up quickly, especially for therapists who are in-network with insurances.
• Finally, you might have a preference for a particular provider: someone you’ve seen before, or feel a particular affinity with, or who has been recommended to you by someone you trust.

In any of these cases, you might find your in-network options don’t meet your needs and out-of-network coverage can help bridge the gap.

If you would prefer to see someone out of network, but the cost is prohibitive, even with your out-of-network benefits, see the next post on expanding your options while managing costs.