Therapy & Insurance 101

A simple guide to checking your mental health coverage

Quick disclaimer: This is general information. Every plan is different and rules change. Always call the number on the back of your card to confirm your specific benefits before starting therapy.

• Deductible
  What you pay out of pocket each year before your plan starts to share costs.
  Example: If your deductible is $1,500, you typically pay the first $1,500 of covered services.
• Copay
  A fixed dollar amount you pay per visit (often $20–$40). Depending on your plan, copays may apply before or after the deductible.
• Coinsurance
  A percentage you pay after the deductible is met (e.g., you pay 20%, insurance pays 80%).
• Out‑of‑Pocket Maximum (OOP Max)
  The most you will pay in a plan year for covered services. After you hit this amount, the plan pays 100% of covered costs for the rest of the year.
• In‑Network Provider
  A therapist who contracts with your insurance. Your cost is usually lowest here.
• Out‑of‑Network (OON) Provider
  A therapist who does not contract with your plan. You may still get some reimbursement, but you’ll usually pay more up front and submit claims yourself.
• Superbill
  An itemized receipt your out‑of‑network therapist can give you to submit to insurance for possible reimbursement.
• Authorization / Pre‑Authorization
  Advance approval some plans require before therapy is covered. If needed and not obtained, claims may be denied.
• Carveout
  When mental health benefits are managed by a separate company from your medical plan. Your ID card may list a different number for behavioral health.
• Good Faith Estimate (GFE)
  A cost estimate you can receive when you’re not using insurance (cash/self‑pay).
• EAP (Employee Assistance Program)
  A workplace benefit that may cover a small number of counseling sessions at no cost to you; separate from regular insurance.

• Insurance ID card
• Your full name and date of birth
• Provider’s name (if you have one) and CPT code 90837 (60‑min individual therapy) or 90834 (45‑min) for reference
• Provider’s NPI and tax ID (ask the office if you have a specific therapist in mind)

Ask these questions and write down the answers:

1. What are my outpatient mental/behavioral health benefits?
2. What is my deductible for mental health, and how much has been met this year?
3. What is my copay or coinsurance for therapy sessions (CPT 90834/90837)?
4. Do I need pre‑authorization for counseling/therapy? If yes, how do I get it?
5. Is there a limit on the number of sessions per year?
6. What is my coverage for out‑of‑network providers? (Ask about deductible, coinsurance, and whether claims are paid to you or to the provider.)
7. Are telehealth sessions covered? (Any platform/location rules?)
8. Is my plan managed by a separate behavioral health company (a “carveout”)? If yes, ask for that phone number/member portal.
9. Do I have EAP sessions available? If yes, ask how to access them.

• Is the therapist in‑network for your specific plan? (Plans under the same brand can differ.)
• Do you need a primary care referral or a diagnosis on the claim?
• Are there state/location restrictions for telehealth (e.g., must be physically located in the same state as your therapist during sessions)?
• Are there late cancellation rules that insurance won’t cover? (You pay these directly.

“Hi, I’m calling to verify my outpatient mental health benefits. I may see a therapist for individual psychotherapy (CPT 90834 or 90837). My member ID is ______.
• What’s my deductible and how much have I met?
• What’s my copay or coinsurance for in‑network therapy?
• Do I need pre‑authorization?
• Is there a session limit?
• If I choose an out‑of‑network therapist, what is my OON deductible and coinsurance? How do I submit claims or superbills?
• Are telehealth sessions covered?
• Is mental health managed by a separate company (a carveout)? If so, what’s the contact info?”

• Same brand ≠ same network. A therapist in‑network for one plan (e.g., PPO) might be out‑of‑network for another (HMO/EPO).
• Deductible timing matters. If your deductible resets on January 1, your cost may change mid‑treatment.
• Ask about telehealth rules. Some plans require specific platforms or your location in a covered state at the time of service.
• Know your OON process. If seeing an out‑of‑network therapist, ask: Where do I send the superbill? What forms do I need? How long for reimbursement?
• Use HSA/FSA dollars for copays, coinsurance, or self‑pay.
• EAP first. If you have EAP sessions, you may want to use those before starting regular insurance billing.

1. Pay the therapist at the time of service.
2. Get a superbill from your therapist (it lists diagnosis code, date, CPT code, fee, NPI, tax ID).
3. Submit to your plan (member portal or claims address) with any required claim form.
4. Track reimbursements and save EOBs (Explanation of Benefits).

Member Name: ____________________   

ID #: ____________________
Plan/Carrier: ____________________   

Group #: ________________

Date:____________________   

Rep Name/ID:____________________   

Phone/Ext:____________________   

Reference # ____________________  

Summary of Answers ____________________   

• Full name, DOB, phone, and email
• Insurance member ID and group number
• Photo of your card (front/back)
• Primary insured name and DOB (if not you)
• Any authorization number if required
• Whether you plan to use in‑network benefits, OON reimbursement, or self‑pay/GFE

This guide gives you a clear starting point to avoid surprise bills and reduce stress. Since every plan is unique and benefits can change, always confirm your specific coverage with your insurance provider before beginning therapy.