Is my therapy covered by health insurance?

“To sum it up…”

If your insurance covers mental health services, the coverage should be equivalent to the coverage you receive for physical health care (i.e. if your specialist copay is $50 then your therapy copay should not be more than $50).
The Affordable Care Act requires insurance policies issued through exchanges to offer mental health services.
Studies show that most employer-based policies cover some mental health services.
Some screening services are covered as preventative care, but most insurance coverage for therapy requires a person to have a diagnosable mental illness first.

In recent years, more mental health services have been eligible for payment through health insurance due to the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act. However, there are still policies that do not cover mental health services. There are also policies that require a patient’s deductible to be paid before the insurance policy will begin paying for therapy.

Since 1 in 5 U.S. adults will experience mental health issues each year that could benefit from treatment, it is good that people needing mental health services are receiving some assistance in paying for those services through their insurance. There is a separate article addressing physical therapy or physiotherapy.

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What insurance policies are required to provide mental health benefits?

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Although there have been significant improvements in the number of policies that cover mental health benefits in recent years, it is not a universal requirement yet. Thus, some policies that do not cover mental health services.

Generally speaking, policies obtained through employers with 50 or more employees, policies obtained through the Affordable Care Act healthcare exchanges, and Medicaid or Children’s Health Insurance Program policies will cover mental health treatment and therapy. The policies that are most likely to not have mental health benefits are policies obtained through employers with fewer than 50 employees and Medicare.

Always check your summary of benefits to see if your insurance covers mental health benefits and call the insurance company to ask questions if it is unclear.

What is therapy?

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For conversational purposes, therapy, or psychotherapy, or counseling, is using the services of a trained counselor, therapist, or psychologist, to work through and resolve a wide variety of issues that are impacting one’s quality of life. These problems can include problematic behaviors, intense feelings that interfere with day-to-day life, relationship issues, physical responses to emotional distress, and distorted cognitions.

Therapy can be provided to an individual, to couples, to families, and in groups sharing a common concern.

Individual therapy is one-on-one work between a person and a therapist.
Family/Couples therapy is multiple people working together on a relationship with the assistance of a therapist.
Group therapy can be between three and twelve individuals who are not related but who all share similar problems, such as depression, working with a therapist to improve the problem.

In insurance terms, therapy, psychotherapy, or counseling, is represented by 24 different CPT codes and some add-on codes. CPT codes are five digit numerical codes used to indicate what services have been provided to a patient. Add-on codes are other codes that provide more detail about the conditions under which a CPT code has been performed.

If you seek services from someone without prescription writing authority, such as a licensed professional counselor, a licensed marriage and family therapist, or a licensed clinical social worker, then the most common CPT codes for therapy are 90832, 90834, 90837, 90846, 90847, and 90853.

The first three codes are for individual therapy, the next two are for family/couples therapy, and the last is for group therapy. For a CPT code to be paid by the insurance company, it must also be accompanied by a diagnosis or ICD-10 code.

How do I know if my insurance covers therapy?

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Most insurances are required to cover therapy at this time. However, it is important to verify what conditions an insurance company may place on receiving therapy benefits. Some companies may not pay for treatment of pre-existing conditions.

Other companies may only pay after a patient has satisfied his or her deductible. Some companies will only pay for therapy that is conducted using empirically verified techniques such as cognitive behavioral therapy, so if a patient wants to spend years on a Freudian-style couch, insurance will not pay for it.

A plain language outline of your benefits should be included in the summary of benefits that came with your policy paperwork. However, it is wise to call and speak to a representative to ask whether “individual therapy,” “family/couples therapy,” or “group therapy” are covered.

Using the CPT codes above will help provide more accuracy and clarity in the conversation with the insurance representative about these benefits.

Even if my insurance covers therapy, should I use insurance to pay for it?

One thing to think about before using insurance benefits to pay for therapy is that the professional will also have to assign a diagnosis for the insurance company to agree that the service was used appropriately and is payable.

A private pay client seeking therapy can receive assistance without a label of illness and instead focus on solving the problems that caused them to seek therapy in the first place. At this point,

At this point, the preventative benefits for therapy are limited to services such as depression screening performed by a physician and not wellness checks with a mental health professional.

Conclusion

As of this article, most insurance policies cover some therapy services. However, there are still a few that do not. Check the summary of benefits to see whether individual therapy, group therapy, or family/couples therapy is an included benefit.

If the summary of benefits is unclear, call the insurance company and ask questions about the types of therapy provided and the types of providers the insurance company recognizes as qualified to provide that service.

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