Demystifying Out-of-Network Benefits for Therapy

So 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. There are many factors that you might take into account when searching for a therapist. Usually these factors are based on your personal preferences, such as type of therapy, expertise, cultural background, and therapeutic style. For example, if you are searching for a therapist who has expertise in grief, alcohol use, insomnia and is familiar with Latino culture 🙋🏻‍♀️ — 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 has signed a contract with your insurance company and has agreed to receive a specific payment for their services, regardless of their private pay fee. 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 company 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 a therapist who is not in-network. 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.

Insurance companies typically have a “plan allowance” which is the maximum amount they are willing to pay for a therapy session. The percentage of the plan allowance that you pay is called a “co-insurance.” Your co-insurance usually kicks in once your have completely paid your deductible. A deductible is the amount of money you have to pay out-of-pocket for services before your insurance company starts to reimburse you.

People who use their OON benefits usually pay the full session fee upfront and then submit a superbill, a detailed receipt with billing codes and diagnosis, to their insurance company for reimbursement.

For example, let’s say your therapist charges $200 for 50 minute therapy sessions. You have a 40% co-insurance and a plan allowance of $150, meaning your insurance company will reimburse you 60% of the plan allowance ($90) and you are responsible for 40% of the allowance ($60) plus the remainder of the session fee after deducting the allowance ($50).

Therapist fee: $200

Plan allowance: $150

Co-insurance: 40%

Total client fee after deductable: $110

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.