In Network/In Network provider- This means that the provider has signed a contract with Insurance company A that they will accept this plan and agree to a negotiated discounted rate (also called the contracted amount, sometimes the allowed amount… just to make everything more confusing sometimes the terms change or different companies will call the same thing by a different name.)

So for example, a therapist’s rate is $200 for an initial session, but since they are in-network with your insurance Green Cross Green Shield, they have agreed to a discounted rate of $120.

Deductible- This is the amount you pay for a covered service before the insurance plan starts to pay. For example, with a $1,000 deductible, you pay the first $1,000 of covered services for yourself and then insurance starts paying. Typically, after you meet the deductible insurance will either pay 100% or you will a pay a portion (copay/coinsurance explained more below). Here’s where things get tricky… some plans have separate deductibles for different services or sometimes the plan will pay the full cost before you even meet the deductible. There seems to be no rhyme or reason for this, so make sure you verify your benefits accurately.
Also, family plans may have an individual deductible and a family deductible.

Copay- this is a fixed amount that you pay for a covered service and may take effect after you’ve paid your deductible, or if the deductible doesn’t apply then you pay it from the start. Some plans will give you 3 free sessions a year before the copay starts applying.

You are on your 10th session with your therapist and now all you owe is your copay of $30. So you pay your $30 for the session, your therapist (or their awesome billing person) sends in the claim to insurance and they approve the service and insurance sends a check to the therapist for $80.

Coinsurance- Similar to a copay, this is a percentage of costs that you pay instead of the fixed amount like a copay.
You have a coinsurance instead of a copay and you paid your deductible. Your coinsurance is 20%… so you pay $22.00 (20% of $110) and insurance sends the therapist a check for other $88.00 (80%).

What if the provider is not In Network??

Out of Network-This means that the provider has not signed an agreement with the insurance company. You may have out of network benefits… and this could mean a deductible (possibly separate from the In Network) that you have to meet first, a copay or coinsurance). Part of the agreement between a therapist and the insurance company when they are In Network, is that the therapist will send in the claims to the insurance company and then collect the money from the insurance company and then from the client. Typically, with out of network billing, the client is responsible to pay the therapist 100% of their rate (not the discounted rate) up front, and then the therapist gives the client a superbill (like a receipt) which the client can then submit to insurance. Insurance reviews the superbill, decides what the plan covers, and then sends the reimbursement back to the client.

For example, the claim is sent in by the therapist and now insurance is saying that they either don’t cover the service or instead of only having a $10 copay now you have a $2,000 deductible. Unfortunately, this happens so take notes and keep them somewhere important!

Questions to Ask when Verifying Insurance Benefits:

1. Does my plan cover mental health benefits for an office visit? (even if it’s virtual, it’s still categorized as an office visit)

Specify if it covers these CPT codes are covered: 90791 (initial assessment); 90837, 90834, 90832 (follow up appointments based on time limits)

2. Does my plan cover telehealth appointments with ANY provider? (vs. just through a specific company such as Teledoc or MDLive.)

3. Do I need to meet a deductible? If so:
a. How much is it?
b. How much have I met it already or how much is remaining?
c. Does it apply to the mental health services I’m looking for?
d. When does the deductible restart? (deductibles reset to $0 every year)

4. Is there a copay or coinsurance that I should be aware of?

5. Does my plan limit the number of appointments per year?

6. Do I need to get prior authorization and if so, what is that process?

7. You can also verify if I am in network… certain plans such as BCBS have multiple separate plans that I am not under… for example I am not currently (as of 2022) in network with Blue Home or Blue Local in North Carolina.

If you have more questions, don’t be too shy about pestering your insurance company… that’s what we pay them for! I am also happy to help as much as I can… but I am definitely not an expert. I also found this glossary with Healthcare.gov helpful. https://www.healthcare.gov/glossary/ There are way more terms than I have room (or than we have the attention span) to address here!

Happy Insurance Calling!

-Amy Neal MA, LCMHC