Considering insurances in-network and out-of-network
There are many ways to approach paying for therapy. Usually the most cost-effective approach is to choose an in-network provider. Here at STG we have therapists in-network with BCBS PPO, United Healthcare, CIGNA/Evernorth, and Aetna. Every policy and plan is a little different, so we recommend calling the number on the back of your insurance card to find out how Mental Health services are covered by your plan, if you have a deductible, and what your copay or coinsurance might be. It’s also a good idea to ask if you require any pre-authorization for therapy services.
We have some therapists at Starks Therapy Group who do not accept insurance and are Out-Of-Network (OON) providers. What this means is that these therapists are not in-network with any insurance plans. The client pays at time of service; we give you a receipt, you submit that to your insurance company, and they can reimburse you back. Your insurance company will pay you back based on your OON benefits. Most policies have both in-network and OON benefits. You will want to call your insurance to find out what your OON and in-network benefits are.
Some insurance providers will consider covering OON therapists’ services at your in-network benefit rates. Our OON providers have training and expertise in treating certain diagnoses or using specialized treatment methods that are difficult to find in our area. If you are seeking an OON clinician for a specific type of therapy or to treat a particular problem and have not had success finding someone in network, you will want to advocate that our OON services be reimbursed to you at an in-network rate.
In order to do this, you will need to call your insurance company. You can find the number on the back of your card. Speak to someone in Mental Health and ask for what is called an In-Network Exception. It may go by a different name with your insurance. In-Network Exception is the BCBS PPO term. United uses a Network Gap Exception Request Form. This allows you to get covered for an OON provider at your in-network rates.
Before you call, check out these In-Network Exception guides for Autumn Starks and Binita Donohue. They contain the information you will need to call. Often you need to meet with a therapist at least once to determine if this is a benefit that is appropriate for you to use unless you have had prior mental health treatment with a clear diagnosis or have been referred by another professional.
If you have any questions about your treatment and payment options, please reach out to us. We know that paying for therapy can be stressful and confusing. Part of finding a therapist who is a good fit is finding a therapist who you can consistently afford to see. We are not able to guarantee coverage, but we can talk you through what we know and point you in the right direction.
SAMPLE SCRIPT [VERIFYING YOUR INSURANCE BENEFITS]
Dear Insurance Provider,
This email/call is to inquire about my plan’s Outpatient Mental Health benefits (sometimes called Outpatient Behavioral Health) – specifically, for therapist ______ [name of clinician], their NPI is ______ [get from clinician]. They may or may not be in-network with you.
It would potentially be for service codes:
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90837 (plus 90785 for the intake appointment) (plus if the patient is under 18 yrs old)
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90837: 95 (this is the telehealth version)
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90834 (plus 90785 if the patient is under 18 yrs old)
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90834: 95 (this is the telehealth version)
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What would my copay or coinsurance payment be?
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Are there session limits?
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Do I need preauthorization?
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Do I have a deductible amount to reach before I start to receive these benefits?
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Dear Client,
If your out-of-network benefits have a high deductible or if your reimbursement percentage is lower than you’d like, there is another option called an In-Network Exception. You can find out more information on how to advocate for this with your insurance here.