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  • Writer's pictureConnie Hurst

3 step Guide to out-of-network coverage

PPO and POS insurance plans allow you to choose between in-network and out-of-network therapists. In-network therapists tend to be booked to full capacity with long wait times for appointments. Out-of-network providers can often be a cost effective option that allows you to get an appointment quickly. 

1. Check your out-of-network benefits 

A deductible is the amount you have to pay upfront before your insurance coverage kicks in. If you have a $6,000 deductible and you haven’t had any other medical expenses 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 can be effectively the same cost.  Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.

Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.” In this case, if you spend $1,500 on therapy services, you’ll pay $1,000 out of pocket but a portion of the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit the superbill). 

Sometimes using your out-of-network benefits are more affordable to your standard copay to see an in-network therapist. Good out-of-network coverage may reimburse you as much as 80% of each session fee.  

Co-Insurance is the percentage of the service fee that you’re ultimately responsible for paying. Some insurance companies have an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will reimburse you up to $75 of the therapist’s session fees. 

2. Call your insurance company to verify your benefits

Call the phone number on the back of your insurance card or through your online insurance platform.

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?

  • How do I submit Superbills for reimbursement? 

3. The provided Superbill is all you need for out of network reimbursement

Superbills are documents 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. Depending on your specific plan, your insurance company mails you a check to reimburse a portion of that cost. I email clients superbills  at least once monthly. The app “Reimbursify” can help you navigate the reimbursement process in a few clicks.)

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