There’s a lot of lingo involved in paying for therapy. If you’re trying to find a therapist who fits your needs, figuring out the difference between “in network,” “out of network” and “self-pay” can add another layer of complexity.
An out-of-network therapist is a provider who doesn’t have a contract with your specific health insurance plan. Depending on your benefits, your insurance company may still cover part of the cost of seeing them. But you may have to pay the therapist’s full fee upfront, meet a separate out-of-network deductible and submit a claim before receiving reimbursement.
And not every insurance plan includes out-of-network benefits.
That doesn’t necessarily mean you should rule out an out-of-network therapist. You may find a provider with expertise that matches your needs, greater availability or another quality that’s important to you.
Before making an appointment, though, it’s helpful to understand exactly how your benefits work and what you could end up paying.
Here’s what to know about out-of-network therapy, including how reimbursement works, what a superbill is and what to ask your insurance company before your first appointment.
What does out-of-network therapy mean?
A healthcare provider’s “network” refers to the providers and facilities that have contracted with your health insurance plan.
An in-network therapist has an agreement with your particular plan that generally includes negotiated rates for covered services. Depending on your benefits, you might be responsible for a copay, deductible, coinsurance or some combination of these costs.
An out-of-network therapist does not have that agreement with your particular health plan.
That distinction is important because a therapist can accept one insurance plan while being out of network with another. Simply saying that a therapist “takes insurance” doesn’t necessarily tell you whether they’re in network for your specific plan.
If you see an out-of-network therapist, your plan may cover some of the cost if you have out-of-network mental health benefits. Other plans may provide little or no coverage for routine out-of-network therapy.
Federal mental health parity protections apply to many health plans and require certain mental health and substance use disorder benefits to be treated comparably to medical and surgical benefits. These protections can apply to financial requirements such as deductibles and coinsurance as well as treatment limitations. Outpatient out-of-network care is one of the benefit classifications addressed by federal parity rules. Still, the specific benefits available to you depend on your plan.
Does insurance cover out-of-network therapy?
It can, but it depends on your insurance plan.
If your plan includes out-of-network mental health benefits, it may reimburse you for some of the cost of eligible therapy after you meet any applicable deductible.
Other plans may not cover routine out-of-network care at all, except where different requirements apply, such as certain emergency services.
That’s why it’s a good idea to verify your benefits with your insurer before starting treatment rather than assuming that submitting a claim will result in reimbursement.
When a therapist is out of network, the payment process can also be different from what patients are accustomed to with an in-network provider.
When a therapist is out of network, they get paid right away, but the client ends up waiting to get paid back.
In many cases, that means paying the therapist’s fee yourself and then seeking any reimbursement available under your plan.
How much does out-of-network therapy cost?
There isn’t one standard price for out-of-network therapy. Your final cost can depend on several factors, including:
- The therapist’s session fee
- Your out-of-network deductible
- How much of that deductible you’ve already met
- Your plan’s coinsurance or reimbursement rate
- The amount your insurer considers eligible for reimbursement
- Whether the particular service is covered by your plan
Understanding those terms can help you estimate what therapy might actually cost you.
Out-of-network deductible
A deductible is the amount you generally have to pay for covered services before your insurance plan begins paying its share.
Some plans have a separate deductible for out-of-network services. That means meeting your in-network deductible doesn’t necessarily mean you’ve met your out-of-network deductible.
If you haven’t met the applicable deductible, you may have to pay the full cost of eligible out-of-network sessions until you do.
Coinsurance
After you meet your deductible, your plan may pay a percentage of eligible out-of-network costs while you’re responsible for the rest.
This is often referred to as coinsurance.
But there’s another important number to understand: the amount your insurer recognizes for the service.
Allowed amounts
Your therapist’s fee and the amount your insurer uses to calculate reimbursement aren’t necessarily the same.
For example, imagine your therapist charges $200 for a session. Your insurer might determine that the eligible or allowed amount for that service is $150.
If your plan reimburses 60% after you’ve met your deductible, reimbursement may be calculated using that $150 amount rather than the therapist’s full $200 charge. Your actual benefits and terminology will vary by plan, so ask your insurer how it calculates payment for out-of-network mental health services.
Also keep in mind that out-of-network expenses don’t necessarily count toward the same out-of-pocket limit as in-network expenses. For example, the federal out-of-pocket limit for Marketplace plans does not include out-of-network care or charges above a plan’s allowed amount.
How does payment work with an out-of-network therapist?
In many cases, you’ll pay the therapist’s full session fee at the time of your appointment.
If your plan includes applicable out-of-network benefits, you may then submit a claim to your insurer and receive reimbursement according to your plan’s rules.
Sometimes a therapy practice will submit out-of-network claims for patients. Other times, you’ll be responsible for submitting the paperwork yourself.
Ask your therapist or their billing office about the process before your first appointment.
If you need to file the claim yourself, your therapist may provide a document called a superbill.
What is a superbill for therapy?
A superbill is a detailed document that a healthcare provider can give you to support an insurance claim.
Unlike an ordinary receipt, a superbill generally contains information an insurer may need to process the claim, such as information about the provider, dates of service, fees and relevant billing or diagnosis codes.
Receiving a superbill does not guarantee that your insurer will reimburse you. Your plan will determine whether the service is covered and how much, if anything, it will pay.
Before starting therapy, ask both your therapist and your insurer what documentation you’ll need if you plan to seek out-of-network reimbursement.
How do you submit an out-of-network therapy claim?
The exact process varies by insurance company.
If your therapist doesn’t submit the claim for you, you may need to:
- Pay the therapist for your session.
- Request a superbill or other required documentation.
- Complete your insurer’s out-of-network claim form.
- Submit the claim and supporting documentation through your insurer’s website, app or another accepted method.
- Wait for your insurer to process the claim.
- Review your explanation of benefits, or EOB, to see how the claim was processed and what amount, if any, the insurer will reimburse.
Your EOB isn’t a bill. It explains how your insurance company processed a healthcare claim, including what the provider charged, what the plan covered and what you may owe.
Processing and reimbursement timelines vary, so ask your insurer how long out-of-network mental health claims typically take.
It’s also worth finding out how long you have to submit a claim. Some plans impose filing deadlines.
What should I ask my insurance company about out-of-network therapy?
If you’re considering an out-of-network therapist, call your insurer using the member-services number on your insurance card or check your plan documents.
Have the therapist’s information available if possible, and consider asking:
- Does my plan include out-of-network benefits for outpatient mental health services?
- What is my out-of-network deductible?
- How much of that deductible have I already met?
- What happens after I meet my deductible?
- What coinsurance or reimbursement rate applies?
- How do you determine the allowed or eligible amount for an out-of-network therapy session?
- Could I be responsible for the difference between the therapist’s fee and the amount the plan recognizes?
- Do I need prior authorization or a referral?
- Are there limits on the number or frequency of covered therapy sessions?
- Is teletherapy covered under my out-of-network benefits?
- Do I need to submit a superbill?
- What billing or diagnosis information does the claim need?
- How do I submit a claim?
- Is there a deadline for submitting it?
- How long does reimbursement typically take?
Consider taking notes during the conversation, including the date and any reference number the insurer provides.
Does insurance cover out-of-network teletherapy?
Possibly. As with in-person therapy, coverage for teletherapy depends on your health plan, the provider, the service being delivered and applicable requirements.
If you’re planning to see an out-of-network therapist virtually, don’t assume your benefits will be identical to your benefits for in-person care.
Ask your insurer specifically whether your out-of-network mental health benefits cover telehealth and whether there are different reimbursement requirements.
Why might someone choose an out-of-network therapist?
When you have a choice, staying in network can help keep your costs more predictable. But cost isn’t the only consideration when choosing a therapist.
Sometimes, you may have difficulty finding an in-network therapist who is accepting new patients. You might also find an out-of-network therapist whose expertise or approach is particularly well suited to what you’re seeking.
Some patients choose out-of-network providers because they’re looking for a particular type of care or flexibility.
Other reasons someone might consider an out-of-network therapist include:
- Finding a therapist who specializes in a particular condition or treatment approach
- Continuing with a therapist after changing insurance plans
- Finding a provider with availability that works with your schedule
- Seeking a therapist who offers telehealth or is conveniently located
- Looking for a provider who meets particular language or accessibility needs
Ultimately, choosing a therapist involves weighing clinical fit, availability, convenience and cost.
What are the downsides of out-of-network therapy?
The biggest consideration for many people is cost.
You may need to pay the therapist’s entire fee upfront, even if you’ll eventually receive some reimbursement. Depending on your plan, you may also have a separate out-of-network deductible or receive reimbursement based on an amount that is lower than the therapist’s actual fee.
There can also be more administrative work. You might need to collect superbills, submit claims, track reimbursements and contact your insurer if a claim is denied or processed differently than expected.
And if your plan doesn’t include applicable out-of-network benefits, you could be responsible for the full cost.
Understanding these details before your first session can help prevent unexpected expenses.
What if I can’t afford out-of-network therapy?
If an out-of-network therapist seems like a good fit but the cost is a concern, ask about your options before assuming therapy is out of reach.
Some therapists may offer sliding-scale fees based on income or other circumstances. You can also ask about payment plans or lower-cost services, where available.
If you have a health savings account (HSA) or flexible spending account (FSA), some therapy expenses may qualify. The IRS says therapy used to treat a disease can qualify as a medical expense for purposes of HSA and FSA reimbursement, while services that don’t meet the requirements for medical care may not. Check your plan and current IRS rules before using those funds.
You can also continue searching for an in-network therapist who meets your needs.
If you decide to pay for care without using insurance, federal rules generally entitle uninsured and self-pay patients to a good faith estimate of expected charges when they request one or schedule qualifying care in advance. If a provider’s final bill is at least $400 more than that provider’s good faith estimate, you may be eligible to use the federal patient-provider dispute resolution process.
Frequently asked questions about out-of-network therapy
Can I see an out-of-network therapist if I have insurance?
Yes. Having health insurance doesn’t prevent you from seeing an out-of-network therapist. The bigger question is whether your particular plan will help pay for the care. Check your out-of-network mental health benefits before starting therapy so you understand what you may have to pay.
How much will insurance reimburse for out-of-network therapy?
There’s no universal reimbursement rate. The amount depends on your plan, deductible, coinsurance, the service you receive and the amount your insurer recognizes for that service. Call your insurer for an estimate based on your specific benefits.
Does out-of-network therapy count toward my deductible?
Eligible services may count toward an out-of-network deductible if your plan has one. They may not count toward your in-network deductible. Check your plan documents or contact your insurer to find out how your deductibles work.
What is a superbill for therapy?
A superbill is detailed documentation from a healthcare provider that can be used to support an insurance claim. It generally includes information about the provider, services, dates, charges and relevant billing or diagnosis codes. A superbill itself does not guarantee reimbursement.
Can I submit a superbill to my insurance company myself?
Often, yes. Many patients seeing out-of-network therapists pay for their appointments and then submit a superbill or other claim documentation to their insurer. Check your insurer’s requirements before submitting the claim.
Can I use an HSA or FSA to pay for therapy?
Certain therapy expenses can qualify as medical expenses for HSA or FSA purposes. According to the IRS, therapy that treats a disease can qualify, while services that aren’t considered medical care may not. Check the rules for your account and the specific service before paying.
The bottom line
An out-of-network therapist may be worth considering when you find a provider who meets your needs but doesn’t participate in your insurance network. But “out of network” doesn’t automatically mean your insurance will reimburse you, or tell you how much therapy will ultimately cost.
Before your first appointment, find out whether your plan includes out-of-network mental health benefits, what deductible and coinsurance apply, how your insurer calculates eligible expenses and what you need to do to submit a claim.
A little research upfront can give you a much clearer picture of what you’ll pay, so you can focus on the part that matters most: finding the right support for your mental health.
Ready to find a therapist who fits your needs? With Zocdoc, you can search for therapists in your area, compare providers, and find appointments that work with your schedule. You can also filter by insurance to help identify therapists who accept your plan, or are in network vs. out of network. Find a therapist on Zocdoc.
The information in this article is provided for general informational purposes only and should not be relied on as medical advice. It is not intended as, and Zocdoc does not provide, medical advice, diagnosis or treatment. Zocdoc does not recommend any specific provider. Find one you’ll love on Zocdoc today.
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