What to Ask Your Insurance: In-Network Benefits

I lived in South America from 2008-2010 mostly to improve my Spanish language skills, but partly because I was kind of fed up with how health insurance works in the United States. Real mature, right? Fast forward and… I still feel that way. Even more so now that I have to deal with insurance as a medical provider. Don’t get me started.
As much as I hate insurance companies and I become upset just thinking about them, I have realized (practicing radical acceptance, over and over again) that it wasn’t doing me (or my clients) much good to complain and get resentful about it. I’m still angry but it fuels my mission (anger is a powerful motivator) to educate clients on how to navigate the insurance world, advocate for themselves, and hopefully for greater change re: health coverage. Below are excerpts from a white page I wrote a year or so ago on what to ask insurance in order to figure out your benefits, questions to ask, and the reasoning behind it so that you gather the information needed to better know what you’re responsible for and prevent getting slammed with an unexpected bill.
What to Ask Your Insurance and Why
In-Network Benefits
If you want to use your in-network insurance benefits, I highly recommend that you verify your coverage with a representative. When you do, ask for and document a reference name or number for the call. If there are any discrepancies between what you are told and what they bill, you can have the call reviewed–yes, they record the calls. If there is an error on the part of the representative, generally the insurance company will not hold you responsible and re-process claims in your favor. When I used to verify benefits in the past, I did this and was given inaccurate information and ultimately the claims were reprocessed in my client’s favor.
First off, I recommend contacting your insurance company and speaking with a representative. You can typically find your insurance company’s member services phone number on the back of your insurance ID card. Logging into a portal to review your benefits can be convenient (if you can remember the password) but usually if there is an issue with your claim it’s likely because you read it wrong or missed the fine print. With a representative, the calls are recorded and can be reviewed. Though they can typically find the call if you remember the date that you called, it is good practice to ask for and document a reference number or representative name.
Firstly, you may want to confirm that the therapist in question is indeed “paneled” or “in-network” with your specific plan. Sometimes your medical insurance and mental health insurance company are not the same or you might have a plan that limits who you can see, e.g., with Medicare Advantage Plans, you can only see Psychologists or Licensed Clinical Social Workers that have opted into Medicare, and have contracted with your insurance’s Medicare Advantage Plan. As this is difficult to know unless you’re consistently dealing with with insurance and benefits — and even then, still confusing! –, it is always best to verify with an insurance representative that the specific provider you wish to see is indeed in-network so you don’t accidentally see someone who is not in-network with your plan. If you want to be even more secure that your session will be covered, you might want to verify that the location where you will go to see the therapist corresponds to the location that the insurance has on file for that therapist. I once saw a podiatrist who was moving practice locations. The podiatrist confirmed that they were in-network with my plan. I called my insurer and confirmed the podiatrist (but not which office location) was in-network. Since I saw the podiatrist at her new practice location and she was not yet fully contracted there, insurance wouldn’t pay.
You’re also going to want to know if you can see that therapist directly or if you’re going to need a referral (often from your primary care physician or PCP) or a prior authorization . This is often a whole bunch of administrative paperwork that needs to be filled out by the referrer or the potential therapist. Even if the potential therapist is in-network, if your plan requires a prior authorization and you see the therapist without obtaining one, your session won’t be covered. Kaiser, for example, generally requires you to go through their intake line, then either refers you to an in-house (within Kaiser) therapist or, if all of their providers are full, issues an authorization to someone contracted with Kaiser.
You might also want to find out if you have a deductible, how much it is, and if it applies to outpatient mental health services. A deductible is a specified amount you have to pay upfront before your insurance plan begins to pay (minus a few circumstances like free preventative care if you see an in-network provider). If you’re on a family plan, your plan will have an individual deductible and a family deductible. Mental health services are not always subject to the deductible. If they are not, then your plan will start paying immediately for covered services and finding out how much your deductible becomes unnecessary.
If your mental health sessions are subject to a deductible, you’ll want to know how much it is, how much you’ve already met of your deductible this “year,” what kind of policy year you have (calendar or plan), and what your out-of-pocket-max is. Say your deductible is $5,000 and your mental health sessions are subject to the deductible, you’re going to have to shell out $5,000 in medical costs before insurance will pay a cent. However, you might have an out-of-pocket max of $7000, which means, once you’ve paid $7000, your insurance will cover everything else for the rest of the plan year. Calendar year means your deductible resets January 1. Plan year is a 12-month period of coverage that starts at a date specified by the plan. If you have a plan through your university, your plan year might begin/restart in September. I’ve even come across university plans where the “year” was every quarter, meaning the deductibles reset every 3 months! With this information, you can do some calculating to see how long it might take you to meet your deductible and your out-of-pocket max.
After figuring out your deductible situation, which is one type of cost-sharing, you’ll want to find out what your responsibility is for each session. Sometimes you can find out your co-pay (flat $ rate) or co-insurance (percentage of the contracted rate) listed on the front of your insurance card. Sometimes a mental health provider is considered a specialist (higher co-pay than your PCP) but not always. Another reason I like to talk to a representative. If you do have a deductible, you will also want to ask if your co-pay or co-insurance counts towards your deductible; if yes, you will be paying down the deductible faster than if not. You are responsible for your co-pay or co-insurance for each session until you reach your out-of-pocket max.
Questions to Ask
In-Network Benefits
Is [name of therapist/NPI number] “in-network” or “paneled” with my plan?
Do I need a prior authorization or referral for any of the following outpatient mental health services/CPT Codes?
- 90791 – Intake Appointment
- 90837 – Individual Psychotherapy, 60 minutes
- 90834 – Individual Psychotherapy, 45 minutes
- 90847 – Couples/Family Psychotherapy, conjoint with patient present
- 90846 – Family Psychotherapy, without patient present
- 90839 – Crisis Psychotherapy
Are outpatient mental health services subject to my deductible? I.e., Does insurance begin to cover sessions before or after I meet my deductible?
What is my in-network deductible for outpatient mental health visits?
How much of my deductible has been met this year? I.e., What remains for me to pay out-of-pocket before my insurance coverage kicks in?
What is the policy year (calendar or plan)? I.e., When does my deductible/out-of-pocket max reset?
How much is my co-pay (dollar amount) or co-insurance (percentage)? I.e., what is my responsibility? Does my co-pay or co-insurance count towards my deductible (if services are subject to the deductible)?
Is there a limit to the number of sessions my plan will cover per year? If yes, how many sessions?
Do I have a limit on out-of-pocket expenses per year (out-of-pocket max)? If yes, how much is it and how much remains to be met?
Calculating Your Responsibility
In-Network Benefits
If your outpatient mental health services are subject to a deductible and you have not yet met your deductible, you are responsible for the therapist’s contracted rate with your insurance until your deductible has been met. This rate varies by insurance company, location, type of service, and type of provider. You will need to find out your potential therapist’s contracted rate with your insurance, not their full rate fee. If you have already seen the therapist, you can find the contracted rate on your explanation of benefits (EOB) statement from your insurance as the “allowed charges” amount. Once your deductible has been met, your insurance will begin covering the allowed charges amount, minus your co-pay or co-insurance amount if you have one. If you have a co-pay, you are responsible for that flat amount. If you have a co-insurance, you are responsible for that percentage of the allowed charges/contract fee. Your co-insurance will change per type of session (group, individual, intake, crisis) as well as length of session (30 minutes, 45 minutes, 60 minutes) because each may have a different contracted rate.
For example, if you have met $1400 of a $2000 deductible and mental health services are subject to your deductible, your therapist’s contracted rate with your insurance is $150 and your first session intake rate is the same as all subsequent sessions, your co-insurance is 20%, and your co-insurance does not count towards the deductible:
You are responsible for paying $150 until you meet the $2000 deductible.
Remaining deductible($2000 – $1400) = $600.
Co-insurance (20% of $150) = $30.
Insurance responsibility once deductible is met (80% of $150) = $120.
Money applied towards the deductible each session (Contracted Rate – Co-insurance) = $120.
You will meet the remaining $600 deductible ($600/$120) = 5 sessions.
- Session 1 – Pay $150, $120 paid towards deductible.
- Session 2 – Pay $150, $240 has been paid towards deductible.
- Session 3 – Pay $150, $360 has been paid towards deductible.
- Session 4 – Pay $150, $480 has been paid towards deductible.
- Session 5 – Pay $150, $600 has been paid towards deductible. Deductible has been met.
- Session 6 – Pay $30. Insurance pays $120.