How Does Insurance Work for Couples Therapy?

Once you get through the mental hurdles (deciding to let someone in on the most intimate part of your relationship, realizing your current dynamic isn’t working, and admitting you need help figuring it all out) and land on going to couples therapy, unfortunately there’s a financial obstacle you need to consider before you get to the other side of a healthier, happier relationship: Insurance.You‘ve likely learned a ton relationship gems from Couples Therapy’s Dr. Orna, but you never quite hear exactly how her clients pay to see her. Health insurance (if you’re lucky enough to have some these days) is confusing enough on its own—so how does it work when there’s a whole additional person involved? We asked psychotherapist and managed care consultant Dipesh Patel, LCSW to break down how insurance works with couples therapy and even how to navigate it when you’re uninsured. Taking the step to seek professional help for your relationship is intimidating enough—figuring out how to pay for it shouldn’t be.Does Health Insurance Usually Cover Couples Therapy?Unfortunately, like most things in the world of health insurance: it’s complicated. Patel says that insurance will usually only cover couples therapy if at least one partner has a diagnosed mental health condition and the therapy is deemed “medically necessary.”“Just having relationship issues is not enough to meet the criteria of medical necessity,” he explains. “While couples therapy might involve two individuals there needs to be an identified client who’s mental health diagnosis is the focus of couples therapy.”What Should Couples Ask Their Insurance Company Before Booking a Therapist?Before booking your appointment and getting to the root of any issues you’re having, you’re going to have to make a few phone calls. First, Patel recommends verifying with both the couples therapist and the insurance company directly how much their out-of-pocket costs will be.To get really technical, he suggests using your NPI number and Tax ID number to make sure the provider is in network—and then double checking what billing codes will be used when processing payment.What Do Terms Like Deductible, Copay, Coinsurance, and Out-of-Network Benefits Mean in the Context of Couples Therapy?If you barely understand these words when dealing with your own insurance, I’d bust out the note pad for this one. Patel puts each into simple terms. A deductible is the amount you need to pay out-of-pocket before your insurance benefits start to kick in. A co-pay is the fixed amount you pay per service. “For example, if you have a co-pay of $25 for therapy you’ll pay your therapist $25 every time you go to see them,” he explains.Co-insurance is the percentage of the provider’s fee that you’ll pay that’s your responsibility after you meet your deductible. “If you have a 20 percent co-insurance and your therapist’s fee is $200 you’ll pay $40 every time you see them for a session.”Out-of-network benefits are for people who want to see a provider outside of their insurance. “You typically have to pay out-of-pocket upfront and get reimbursed afterwards by submitting a superbill to your insurance or having your provider submit an out of network claim,” Patel says.To check these benefits, he suggests asking about the “benefit allowance” for the billing code, which will give you an idea of how much you can expect to be reimbursed.If you’re checking out of network benefits, I would ask about the benefit allowance for the specific billing code used to give you an idea about how much you can expect to be reimbursed. It’s important to also see if a deductible has to be met first for either in network or out of network providers. “This is one of the most common issues I see couples running into, especially since many times there’s an in network deductible and an out of network deductible that needs to be met separately,” he says.He also advises to always get a call log number or something in writing so that you don’t get misquoted.If You Aren’t Covered, Are There Other Affordable Options?If neither you nor your partner have a diagnosed mental health condition and your insurance won’t cover couples therapy, all hope is not lost. Patel advises looking for therapists that offer sliding scale services.“Many times, couples therapists will discuss what their sliding scale policy looks like, if they have one,” he says. “It’s also okay if you have a set amount to budget for couples therapy and want to see what would be the best way to use that amount. I’ve had many couples come to me to say that they have a certain amount they can use and we’ve been able to figure out a plan that might help them get closer to their relational goals working together.”And if you do some additional digging, you might even find a therapist who is interning or trying to get their hours for their full licensure: Patel says they might even offer pro-bono therapy services.What’s the Biggest Mistake Couples Make When Paying for Therapy?More than anything else, Patel said the biggest mistake a couple can make is assuming health insurance is going to cover their couples therapy.“Health insurance can feel like a maze to travel, but never make any assumptions about your benefits until you’re able to verify them directly with your specific health insurance plan,” he says.While it’s unfortunate that you have to jump through so many hoops to get the help you need, it’s worth it if you think you and your partner would benefit from couples therapy. It’s best to make all the phone calls and figure out finances ahead of time so that you’re not worried about unexpected bills. This way, you can focus on what’s really important: Getting professional validation that your partner was, in fact, the wrong one in your last argument.