Navigating Out of Network Benefits

Navigating therapy options can feel like a big task, especially when it comes to figuring out your out-of-network (OON) insurance benefits. But don’t worry—using your OON benefits doesn’t have to be complicated, and it can open the door to working with a therapist who’s the perfect fit for you. Let’s break it all down step by step, so you can confidently make the most of your insurance and focus on what really matters: your healing.

What Are Out-of-Network Benefits?

Out-of-network benefits let you see a therapist who doesn’t contract directly with your insurance company. Instead of your insurance covering the session upfront, you pay the therapist directly, and then your insurance reimburses you a portion of the cost. It’s a great option if the therapist you want to work with specializes in areas like EMDR or perimenopause-related challenges but isn’t in your network.

How Do I Know If I Have Out-of-Network Benefits?

Check Your Plan

Your insurance policy will have a section about mental health or behavioral health coverage. Look for words like “out-of-network reimbursement,” “deductible,” and “coinsurance.” If you have a PPO you’re likely in luck - HMO’s typically do not offer out of network benefits.

Call Your Insurance Company

Call your insurance company. Their member services number should be on the back of your card.

1. Ask if you have “out of network” benefits for mental health care. They may ask, “outpatient or inpatient?” Our work is considered outpatient care.

2. Find out if you have a deductible that must be met before coverage kicks in. If so, ask them how much you need to pay before your insurance begins to reimburse you for out-of-pocket fees.

3. Ask how much your plan will reimburse you. Ask the representative, “What is the maximum allowed amount for mental health service code 90837 with a therapist, and what percentage of the maximum allowed amount will my plan pay?” This percentage of the maximum allowed amount is the amount you would receive as reimbursement.

4. Are there session limits or required approvals?

Understand Key Terms

• Deductible: The amount you pay out-of-pocket before insurance starts reimbursing you.

• Coinsurance: The percentage of the cost you’re responsible for after hitting your deductible.

• Allowed Amount: The maximum rate your insurance will reimburse for therapy, which may be different from your therapist’s fee.

Real-World Example: How OON Coverage Might Work

Let’s say:

Your therapist charges $185 per session.

• Your insurance plan reimburses 70% of the allowed amount after you meet your $1,000 deductible.

• The allowed amount for therapy sessions is $150.

Here’s how it could play out:

• You pay $185 per session until you’ve paid $1,000 out-of-pocket to meet your deductible.

• After that, your insurance reimburses 70% of $150 (the allowed amount), which is $105.

• You’d pay $80 per session ($185 - $105 reimbursement).

By using your OON benefits, you reduce the cost of therapy while continuing to work with the therapist who best fits your needs!

How to Use Your Out-of-Network Benefits

1. Pay Your Therapist Directly

   You’ll pay your therapist upfront for each session.

2. Request a Superbill

   Your therapist will provide a detailed invoice (called a superbill), which includes all the information your insurance company needs, like session dates and diagnosis codes.

3. Submit the Claim

   Send your superbill to your insurance provider. Most companies allow claims to be submitted online, by mail, or through their mobile app.

4. Get Reimbursed

   Once your claim isprocessed, your insurance company will reimburse you directly—either by check or direct deposit—based on your plan’s terms.

Why Choose Out-of-Network Therapy?

Out-of-network benefits give you the freedom to choose a therapist who truly aligns with your needs, even if they’re not in your insurance network. This can be especially important if you’re looking for specialized services like EMDR for trauma or support during midlife transitions, including perimenopause. Finding the right therapist is about more than convenience; it’s about finding someone who understands your unique challenges and offers the tools to help you move forward.

Making the Most of Your OON Benefits

• Track Your Progress: Keep copies of your superbills and track your reimbursement to stay on top of your claims.

• Consider Your HSA or FSA: Many therapy costs can also be reimbursed through a Health Savings Account (HSA) or Flexible Spending Account (FSA), giving you another way to offset out-of-pocket costs.

• Be Aware of Deadlines: Check with your insurance provider about claim submission deadlines to avoid missing out on reimbursements.

Here are steps to determine if you have coverage:Let’s Get Started

Using out-of-network benefits might seem like an extra step at first, but the payoff is huge—you get access to the therapist who feels right for you and your journey. If you’re feeling unsure about where to start, I’m here to help walk you through the process and provide a superbill each month.

Therapy is an investment in yourself, and with the help of your OON benefits, it can be more accessible than you think. Ready to take the first step? Reach out to me today to schedule your free 20 minute consultation.