USING INSURANCE FOR THERAPY


Nearly every insurance or health benefits plan is (currently) required to cover psychotherapy services, at a level similar to regular medical care.  The specific rules and types of coverage vary so much that we can't possibly explain it all here.

Usually, insurance plans require a specific agreement (contract) with each specific therapist in order to provide the most coverage/least cost to the client-- or sometimes they will only pay for therapy with a contracted  provider.  

It is important that you know what your plan(s) cover and whether the plan will pay for the counselor you choose. We have a handout you can use to help you get the information you need from your insurance company(ies). (see bottom of page)

Our commitment to you:  We will make every effort to provide services which are covered by your insurance plan(s) and to alert you when this is not the case.  However, there are too many insurance and benefit plans in various combinations to be able to track the specific requirements of each situation.  So we expect each client to be in charge of his/her healthcare and health benefits.  You are ultimately responsible for ensuring that your services are covered by your plan for your therapist.  This means that we will possibly give a discount to your insurance company, and then your share of the cost is your normal amount based on this discounted fee.   

We will bill any insurance plans that we have agreements with.  If your plan does not have an agreement with us, we will try to bill the plan for you as a courtesy.  If we are unsuccessful, we can provide you with the necessary billing information to submit your own claim.  

It is important to be aware that insurance plans often have specific rules you must follow in order to have the therapy paid for.  If these rules are not followed, they may not pay.  It is part of your agreement with us that if your company denies payment, then you agree to be responsible for the fees in lieu of using insurance. (with some exceptions)

USEFUL NOTES:
  • Insurance plan coverage varies by therapist.  Check with your insurance company to ensure that your counselor is covered by your plan(s).
    • The therapist is not on your plan?  You might still be able to get the services paid for:  Ask if you have an 'out of network benefit'.  Some plans will pay for counselors who are not contracted with them-- but you may have to pay a larger share of the cost.  
      • You can also ask about a 'single case agreement' or an exception to their policy.  We see this work most often when there is a clear reason to make an exception-- as in when it creates an undue hardship to use an 'in-network' therapist.  Lastly, we have agency "group" contracts with a small number of insurance companies, so they may authorize 'in network' benefits or costs to you even if the therapist is not in-network. 
  • Preauthorization required?  If your plan requires pre-authorization to receive counseling services, we may need to require that we have a copy of the authorization prior to scheduling an appointment. Please allow up to 2 weeks for us to receive the authorization once you have contacted your insurer.  

  • You have more than one insurance plan?  We may be able to bill both plans.  It is important to ask both of your insurance companies if your counselor is on their plan, and what restrictions or rules apply.  
  • Changes to your coverage?  It is essential that you notify us immediately, to prevent any problems in coverage/payment which could cause you to be responsible for the fees.

  • Frequently used terms for insurance plans:  
    • Deductible-- amount of money the patient must spend before the insurance will pay anything for services.
    • In-Network or "preferred provider" or similar terms:  Providers who are contracted and approved to be seen under an insurance plan.  Typically, the amount of the cost to the patient is lower than out of network, or non-preferred.  
    • Copay or copayment:  A set amount, usually, which is the patient's responsibility to pay for service at the time of the appointment.  Copays are usually the same for counseling as they are for other "specialists" in health plans.
    • Co-insurance:  This usually refers to a percentage of the amount of the bill that the patient is responsible for.  
    • Non-covered services/benefits:  These are services that your insurance company will not pay for.  We are seeing more insurance plans that exclude couples'/marriage and family counseling.  You might be responsible for up to the full fee.
 IF YOU HAVE MEDICARE: (CURRENTLY, WE DO NOT ACCEPT MEDICARE, TEMPORARILY)  
  • Only John Ortmeyer and Douglas Chandler can accept Medicare.  
  • Are your Medicare benefits managed by an insurance plan?  You need to check with your insurance company to make sure that  Douglas or John accept that plan.  While they are Medicare-contracted providers, they might not contracted with your Medicare managed care plan.  
  • If you have more than one insurance plan, be sure to check that Douglas or John are on both plans.  
  • Special note about being covered by Medicare AND Medicaid:   Because of the way in which these benefits are regulated, we are unable to accept any patients who have both Medicare and Medicaid (also known as "dual eligible").    If you are not sure if you are dual eligible, please ask your insurance company directly. 

 SPECIAL NOTICE ABOUT PLANS UNDER THE AFFORDABLE CARE ACT (ACA), also known as 'Obamacare', or subsidized/free under the  "Exchange".  
  • We are able to accept some ACA plans, but not all. Be sure to check with your insurance plan. 
  • We cannot accept any plans that are "Medicaid" or "Apple Health". These insurance plans are either free, or may include ACA plans that are subsidized.  These are some plans which may provide coverage under Medicaid/Apple Health:  
    • Community Health Plan
    • Molina
    • Coordinated Care
    • some United Healthcare plans.  
There may be other plans as well.  If you do not know if we can accept your plan, ask your insurance company directly, to find out if the counselor you are interested in is on your plan.  If we are not able to accept your plan, then please see "not covered by insurance" on the Financial Practices page.

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Douglas Chandler,
May 4, 2017, 6:44 PM