Step-by-step guide to out-of-network benefits

Step-by-step guide to using out-of-network benefits

by Maggie Jordan & Yuri Tomikawa

working_2.jpg

When looking for a therapist, you have the option to choose between in-network and out-of-network providers. (In-network simply means the therapist has negotiated a contracted rate with your health insurance company; out-of-network means the therapist does not have a contract with your health insurance company.)

While finding an in-network therapist is often the default choice, including out-of-network therapists can help expand your therapist search, especially in big cities like Boston where therapists who take insurances tend to be full with long wait times.

If the therapist you're seeing is not in your insurance network, then you will have to pay the full price of the session upfront. Fortunately, depending on your plan, your insurance company may help reimburse a portion of the cost by mailing you a check. For example, most PPO and POS health plans offer partial reimbursement for out-of-network services.

Take the following steps to utilize out-of-network benefits. Though navigating out-of-network benefits can be cumbersome, it can saves you a lot of money in the long-run. Even if you don't fully understand the terms below, having the details upfront can help you understand how payment works and how to prevent any unexpected bills.
 

1. Check your out-of-network benefits

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

  • Out-of-network deductible: The amount of money you have to pay before accessing reimbursement. Let's say your deductible is $1,000 and your insurance company pays for 100% of services after you meet that amount. If you spend $1,500 on therapy services, you'll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but you'll have met your deductible at that point. The remaining $500 will be reimbursed to you in the form of a check mailed to you after you submit your claim. The deductible resets every year, and any health expense you pay out-of-pocket contributes to meeting it.
  • Coinsurance: This is the percent of the service fee that you're ultimately responsible for paying. Let's say your therapist charges $100 per session. If your coinsurance is 25%, you'll ultimately be responsible for paying $25. Although you'll need to pay $100 upfront, your insurance will send you a check for $75 after the session, once you’ve met the deductible and submitted a claim (more on this below). Note, however, that insurance companies determine an "allowed amount" which caps the session fee that they'll cover. If the "allowed amount" is $100 per session, your insurance company will only reimburse you up to $75 as in the previous example, no matter what the therapist’s session fees are. If your therapist's session fees are $200 per session and you paid $200 out of pocket, you won't get reimbursed more; you'll still be reimbursed $75 and will be ultimately responsible for $125.
     

2. Call your insurance company to verify

The best way to be absolutely sure of your benefits is to call your insurance company member services line and ask:

  • What is my out-of-network deductible for outpatient mental health? (Outpatient means treatment outside a hospital.)
  • How much of my deductible has been met this year?
  • 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?
  • How do I submit claim forms for reimbursement? (Claims are forms like this that are sent to your insurance company to receive reimbursement for sessions you paid for out of pocket.)

You can find this phone number on the back of your insurance card.
 

3. Ask your therapist for a superbill

When you’re looking for a therapist, ask if they're willing to submit claims to your insurance company for reimbursement. While some therapists offer this, typically, the client is responsible to submitting claims. Your therapist will provide you a document called a superbill that you send directly to your insurance company at the end of each month. The superbill details how many sessions you’ve had and the total fee.
 

4. Receive reimbursement! 

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

 


Maggie Jordan is Zencare's Therapist Success Manager. She is deeply committed to increasing access to care by streamlining the therapist search process, and particularly enjoys connecting LGBTQ+ folks with culturally competent therapists. She is a graduate of Brown University where she competed as a varsity swimmer.

Yuri Tomikawa is the Founder & CEO of Zencare. She was selected MedTech Boston's 40 Under 40 Healthcare Innovators for her work in improving patient access to mental healthcare and has appeared as a keynote speaker on entrepreneurship, mental health, and female empowerment. She is a graduate of Brown University and former management consultant at McKinsey & Company.