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Demystifying Insurance Billing

We understand that insurance can be a complicated and confusing system to navigate. As a collective therapy practice our goal is to help provide access to care for people from all economic backgrounds by accepting some insurance plans that we find are able to support our practice and help us provide necessary services to our clients.


Insurance has many uses, as well as limitations, and we believe that you can best utilize the benefits from your insurance if you have an understanding of what the benefits and limitations are before you seek access to care.


The Affordable Care Act (ACA, or Obamacare as it is commonly known) ensured that all health insurance plans, including medicare plans and small group or individual plans, covered mental health services like (but not limited to) outpatient office visits with a provider and psychiatric medications. This allowed increased access to mental health care for clients and made it more feasible for even private practitioners in mental health to be able to benefit from credentialing and contracting with various insurance networks.


Below we have some commonly asked questions about billing insurance for mental health services. We hope this helps answer some questions, and we are always happy to help you answer any additional questions.


How do I use my Insurance?

Okay, so you have insurance and you know it has to cover mental health! So how do you use it?

First you will want to check with the clinic you are hoping to schedule with that they can bill your plan. You can find a list of our accepted plans Here. Once you know if the clinic can bill your plan, you will want to see if they would be billing your plan as “In-Network (INN)” or “Out of Network (OON).” Not all plans have out of network coverage and most often in-network will provide you with the most coverage and least cost to you. This is plan dependent, however, so we will go over how to figure out your coverage later on.


Can I get couples therapy under my insurance? What about specialized treatments such as sex therapy or EMDR?

Insurances as a whole do not cover “Couples Therapy” billing codes. They will not cover any services that are targeted toward relational issues such as conflict resolution, communication skills, intimacy issues, sexual concerns. Specialized treatments such as Sex Therapy from a Certified Sex Therapist are not covered for couples or individuals. However, many sex therapists do take insurance and can incorporate some of the tools into your therapy under your insurance. If you are coming to therapy specifically for sexual concerns, it may be best to seek out a provider for self pay or under a sliding scale, if you are on a budget, and want to be sure you can focus on your concerns without worrying about the insurance not covering the services.


Specialized services such as EMDR or Family Therapy can be covered by your insurance, just be sure that the provider accepts the insurance plan that you have and check with your insurance that they cover those services.


My provider or clinic says they accept my insurance! What do they need from me?

Your provider will need some basic demographic information from you including:

  • Legal name (the name on file with your insurance or that’s on your state issued ID)

  • Legal gender (the gender on file with your insurance or that’s on your state issued ID, this may be different than your gender identity)

  • Date of birth

  • Phone number

  • Billing address (on file with your insurance)

Each clinic may ask for different details, but these are the base pieces of information needed to bill your insurance.


How will I know what I will owe my provider?

Ideally, your provider or clinic will verify your benefits and be able to tell you a cost estimate. Please note, ultimately it is your responsibility to know your benefits and coverage, legally the contract between you and your insurance and the provider and your insurance company states that you are responsible for any amounts that the insurance will not reimburse. This is why it is so important that you have access to your plan benefit summary and understand the terms of your insurance subscription.


My provider told me what my coverage is, but I don’t understand the terms they told me. What are some common terms that explain my benefit coverage?

There are several terms that come up regularly with our clients at CTC. Here are the terms and their definitions in reference to benefit coverage:


- Copayment: a set amount of money that your health insurance plan sets as your cost-share in the services you seek using your insurance. It is common for copays to range from $10-$60 (sometimes less or more) and then the insurance pays the remainder. This occasionally does not go into effect until a deductible is met, but more often than not with copays your deductible is waived (see your specific plan benefits to be sure)


- Coinsurance: This is a set percentage of cost-sharing that your insurance plan sets for the services you seek to bill the insurance for. This benefit commonly does not go into effect until the plan deductible is met, however there are exceptions where the deductible is waived (see your specific plan benefits to be sure). The percentage you are responsible for commonly ranges from 10%-50% and the rate that percentage is based on is the contracted rate determined by the insurance and the clinic or provider you are seeing.


- Deductible: This is the amount set by the insurance company that you have to meet for any non-preventative services to be covered and your benefits to go into effect. Some plans will waive this amount for mental health outpatient office visits, however, many do not. Make sure you know what your deductible is and if you need to meet it before your benefits go into effect. Billing your services with your insurance will often change the rate you will owe for the services. This rate is decided by the insurance and is referred to as the “allowable amount” or “contracted rate” for what the insurance will reimburse and what the clinic can charge you while billing your plan. This rate will change based on the service type (whether it’s an intake appointment, individual therapy, or family therapy) and the full amount will apply toward your deductible until your deductible is met.


I’m on a tight budget and I need to know my benefits before I seek out care, where do I find this information?

This may depend on your insurance provider, most plans have your benefits accessible online or in an app when you register once your plan is active. This would be found at the insurance providers website. If you do not have access to an account online, your insurance ID card should have a customer service number on the back that you can call to find out benefits for specific services or find out where a full benefit summary can be located or sent to you.


My insurance benefits aren’t affordable for me for mental health at this time, does this mean I can’t get a therapist?

Unfortunately, even if you have insurance, many plans do not have the best coverage and oftentimes it can still be out of reach for clients to access therapy. The good news is: there are many educational institutions and even private practitioners that offer sliding scale rates that can help save you money. If you have a provider or clinic in mind, it doesn’t hurt to reach out to see what options they have! For example, we are a teaching institution at CTC and we offer tiered rates based on the experience level of our providers. You can see our base rates here and if you are interested in sliding scale options, you can let us know when you inquire!


Less than thrilled with your insurance plan?

Trying to access care to necessary services can be difficult and sometimes downright impossible. Valuable services come at a high price, understandably, but the limitations that places on average income earners or folks under the poverty line is identifiably unethical and inequitable. I took a moment to speak with one of our providers, Jessica Broderick, LMFT, to find out more about what WE can do as insurance consumers. Here is what she said:

  1. You can call your insurance and try to make a complaint/comment with customer service and request specific services to be added to your plan. Jessica is not positive that this has a major impact, but the more people who do it, the more likely they will be to listen.

  2. Her number one recommendation to enact change: Support local political advocacy groups!

In Oregon those are ORCA, COPACT, OAMCD, and NAMI.

  1. Learn about the current legislation in the works and be ready to vote!


Final Note from our provider Jessica Broderick LMFT:

“In Oregon, through the direct efforts of COPACT and ORCA, we passed House Bill 3046. This will have a HUGE impact on how insurance companies (private and OHP) are required to cover mental health care in this state. Perhaps this can function as a framework for change to folks in other states? Basically, give those [advocacy] groups your money. Ask them if they need help writing letters, and if they need folks to testify during legislative sessions about their experience. Legislators are so damn out of touch that they need to hear working class people describe to them what seeking care is actually like for us plebeians.”