What Are Out-of-Network Benefits?
November 21, 2022
Understanding your insurance plan is a crucial step for taking advantage of the benefits your plan has to offer, and can make therapy more affordable. Let’s walk through how to find out what your plan covers, and how to estimate the cost.
How do out-of-network benefits work with mental health care?
You’ve taken the step to decide to seek mental health care, congrats! It’s a big one. Now what? How do you know what therapists you can see, and how much will it cost? If you have insurance, this is a good place to start. Therapy can be costly, and insurance terms are confusing. In-network? Out-of-network? In-patient? Out-patient? Make it make sense!
In-network vs. out-of-network insurance for therapy
More than likely, your health insurance plan includes what is called “in-network” benefits. This means your plan covers you to see providers that your insurance has partnerships with. In-network therapists have agreed upon rates with insurance companies, and accept insurance as payment. Many therapists want to focus on providing care, rather than dealing with all of the paperwork and coordination that goes along with being in-network. For this reason, many therapists are not in network.
You might also have “out-of-network” (OON) benefits. Most therapists are out-of-network, meaning they don’t accept insurance as a form of payment. However, if you have OON benefits, it means you can see licensed mental health professionals, and your plan will reimburse you for a portion of the cost.
In-network and out-of-network can easily be confused with “in-patient” and “outpatient” services. In-patient services are provided in a hospital setting, while “out-patient” services are provided outside of the hospital, like at a doctor’s office. If you’re looking to see a therapist outside of a hospital, you will be seeking outpatient Mental health services. Your insurance plan should have your in and out-of-network benefits listed under the “outpatient – mental health”, “Psychotherapy” or “Behavioral Health” service type.
What therapists are usually covered for out-of-network reimbursements?
Licensed clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Licensed Marriage and Family Therapist (LMFT), Licensed Professional Counselor (LPC/LPCC), Psychologist (PsyD), Psychologist (PhD) and Psychiatrists (MD).
How do out-of-network mental healthcare benefits typically work?
OON benefits often mean you will have to pay a therapist their full session fee, submit a claim to your insurance after the session, and later receive a reimbursement check in the mail. Some therapists will submit the claim on your behalf, while others will require you to send the claim yourself. If you are submitting for yourself, your therapist will provide you with a “Superbill” each month, so you can submit sessions all at once. The amount you’ll be reimbursed depends on the deductible, out of pocket max, and coinsurance that your plan specifies.
- Deductible: the amount you must pay out of pocket before your insurance benefits kick in. Before it is met, you will be responsible to pay the full session rate. Keep in mind, other out of pocket medical expenses can apply towards meeting your deductible.
- Coinsurance: the amount you will be responsible for each session after your deductible has been met. You can think of this as a cost share between you and your insurance company. This is typically a percentage. For example, let’s say you’ve met your deductible and have a 20% coinsurance. Your insurance will reimburse you for 80% of the session after you file a claim. For a $100 session, you would be responsible for $20 (20% x session cost), and your insurance would reimburse you $80 (the remaining 80% of the session cost).
- Out of pocket max (OOP Max): the maximum amount your insurance expects you to pay out of pocket (after your deductible is met). Once you reach your OOP Max, your insurance will reimburse you the full amount that they deem customary for a therapy session.
An example of out-of-network mental healthcare benefits
Here’s an example of what your reimbursements could look like. You can think of your reimbursement amount in 3 phases: before you reach your deductible, after you reach your deductible, and after you reach your out of pocket max.
— Example Session cost: $100
— Example Plan: deductible: $1000 / coinsurance: 20%
1. Before you reach your deductible:
- Reimbursement: $0
- Your net cost per session: $100
2. After you reach your deductible:
- Reimbursement: $80 (The session cost minus the coinsurance amount)
- Your net cost per session: $20
3. After you reach your OOP Max:
- Reimbursement: $100 (The full session cost, up to what your insurance company believes is a fair session rate.)
- Your net cost per session: $0
Helpful mental health insurance terms to know
- Allowed amount - the amount your insurance company deems fair and customary for a therapy session.
- Practice - refers to the therapist’s business entity. There can be group practices with multiple therapists, as well as solo practices with only one therapist.
- Coinsurance - the amount you will be responsible to pay after your deductible has been met.
- Deductible - the amount you must pay out of pocket before your insurance benefits kick in.
- In-patient - services provided in a hospital setting, while the patient is admitted to the hospital.
- In-network provider - a provider that accepts your insurance as a form of payment.
- Outpatient - services provided outside of a hospital setting.
- Out-of network provider - a provider that does not work with insurance, but those with OON benefits are still covered to see.
- Out of pocket max - the maximum amount your insurance expects you to pay out of pocket (after your deductible is met0). Once you reach your OOP Max,, you typically do not have to pay a coinsurance or copayment.
- Provider - a general term for a health care professional that provides services. Mental Health providers typically include these types of titles ( LCSW, LMHC, LMFT, PSYD, PHD in Psychology, and sometimes Psychiatrists (MD).
- Superbill - a consolidated bill of all of your therapy sessions for the month. A Superbill for therapy will be submitted as a claim to your insurance so you can get reimbursed.
How we can help: check your OON benefits now
At Nirvana, we believe you deserve to focus on your mental health journey without the stress of how to pay for it. Use our OON Reimbursement Calculator to see if you have out-of-network benefits, the progress of your deductible, and estimate your reimbursement for therapy.