Demystifying Out-of-Network Benefits for Therapy
You found the perfect therapist, but they’re out-of-network …
This is a common dilemma that many people face. First, let’s discuss why someone might want to use their out-of-network benefits rather than finding a provider who is in-network.
You are looking for something specific (type of therapy, expertise, cultural background, language)
You found a therapist that you really connect with, but they don’t accept your insurance
You have a high deductible and would have to pay out of pocket either way
You have good out-of-network benefits and can afford the co-insurance
Finding the right therapist who also takes your insurance might feel like searching for a needle in a haystack. Using your out-of-network benefits allows you to search amongst a larger pool of providers so that you have a greater chance of finding a therapist who is a good fit for you.
What is an out-of-network provider?
A therapist who is “in-network” is a provider who accepts your insurance. Billing happens through the insurance company and you usually only pay a co-pay after the deductible has been met.
An “out-of-network” therapist is a provider who has not signed a contract with your insurance company, but is willing to provide the documentation your insurance needs for you to access your out-of-network benefits.
What are out-of-network benefits and how do they work?
If you have a PPO, your insurance may cover a portion of the fee for services with an out-of-network therapist. There are important terms that you need to know in order to calculate how much you will pay for therapy if you decide to use your OON benefits.
Plan allowance - The maximum amount the insurance company is willing to pay for a therapy session.
Co-insurance - The percentage of the plan allowance that you pay.
Deductible - The amount you have to pay out-of-pocket for services before your co-insurance kicks in.
Superbill - A detailed receipt that includes billing codes and diagnoses.
People who use their OON benefits usually pay the full session fee upfront and then submit a superbill to their insurance company for reimbursement.
How do I find out what my out-of-network benefits are?
It’s a good idea to call your insurance company and verify your out-of-network benefits so that you know exactly how much you will be paying for sessions. Here is a guide on what questions you should ask:
1) Do I have coverage for outpatient mental health therapy?
2) What is my out-of-network deductible?
3) How much of my out-of-network deductible has already been met?
4) What is my policy period?
5) What is my co-insurance?
6) What is my allowed amount (plan allowance)?
Should I work with an out-of-network therapist?
Therapy is an important investment in your mental health and overall well-being. Ultimately, working with an out-of-network provider gives you the freedom to choose a therapist who may be the right fit rather than being limited by insurance. You deserve support that feels aligned and meaningful.
Ready to begin? Reach out today to schedule a free consultation and learn how therapy can help you move toward balance and emotional well-being.
