Can I Use My Health Insurance to Pay for Counseling?

Maybe...probably...hopefully, it depends? Making the decision to seek counseling services is a big step and figuring out how to pay for it is too. The good news is that most commercial health insurance plans, as well as Medicaid and Medicare cover counseling. The tricky part is when and how much. If you don't understand your health insurance plan coverage, you could get an unexpected bill. Review common insurance concepts below and compare them to your plan so you know what to expect. I tried to keep this short, but insurance is complicated!

• Deductibles - this is the single biggest barrier. You know you have health insurance, but you receive a bill for the entire cost of the service. The culprit is your deductible. If you have a $2,000 deductible, you have to pay $2,000 for services, procedures, medications, etc., before your insurance coverage starts. You can track your deductible through your health insurance app or online portal or the paper EOBs you receive in the mail. Some things to remember:

  • Your deductible resets every year, so the earlier in the year you reach it, the more benefit you will receive.

  • There is often a lag between when you pay for a service and when it is deducted from your deductible. Some larger agencies may not submit claims for 4-6 weeks and then it may take another 1-2 weeks before it is processed. You may have met your deductible, but you still get charged full price because the insurance system isn't up-to- date. You will get a refund for anything you pay above your deductible. It just may be delayed by a few weeks while everything is being processed.

  • If you have a deductible, ask your provider how much the service will cost. Your deductible stays the same with any provider you see in your insurance network. There is some variation is negotiated rates between providers in a region as well as between certain providers (e.g., counselors versus psychologists), so it is always a good idea to get a quote for the actual cost.

    
    

• Out-of-pocket maximum - Once you reach this amount, everything should be covered at 100%. They are almost always higher than your deductible, except on some really high deductible plans where they can be the same amount. It's good to know that there are different amounts for individuals and families on the same plan, so if you haven't used your health insurance in a year, your out-of-pocket maximum might be met if your partner or family members have.

  
  

• Co-pays and Co-insurance - A co-pay is a set amount you pay for a defined service or product (e.g., $50 for an office visit, $25 for certain prescription medications) and a co-insurance is a percentage of the total service or product (e.g., if you have 80/20 coverage your insurance covers 80% of the cost, meaning on a $100 office visit, you would pay $20).

  
  

• Superbills and Out-of-Network Coverage - If you choose to see a provider that is not in-network with your insurance plan, you may be able to get a reimbursement if your insurance plan has out-of-network benefits. If you have those, ask your provider if you can have a superbill, which is basically a fancy receipt which includes CPT code(s), diagnosis, date of service, their NPI number, amount paid, etc.). You can submit the superbill to your insurance and they will process it and send you a reimbursement. No, you cannot ask for a superbill before you pay for the session and then use your reimbursement to pay the outstanding balance. The superbill is a receipt of what you paid, so doing that would be insurance fraud.

The best way to avoid surprises is to review your insurance plan coverage, have a discussion with your clinician before you start working together, and verify that they are in-network with your plan. Complete our Contact Us form to schedule your free 20-minute consultation.