Guide to Out-Of-Network Benefits
Are you completely lost when it comes to insurance? If so, you’re not alone. From out-of-network benefits to deductibles, the insurance system can be difficult to understand and navigate. We put this guide together to make it clear (or at least, clearer!) what out-of-network benefits are, how they work, and how to figure out if you have them.
Let’s Start By Breaking Down Insurance
Your insurance comes through a specific provider. Common providers include BlueCross BlueShield, Aetna, and United, but hundreds of other providers exist. Each of these insurance providers has agreements with a collection of therapists. These therapists are “in-network” for a given insurance provider. Individual therapists can decide which providers they want to have agreements with - some therapists will be in-network with multiple providers, some therapists are only in-network with a single insurance provider, and some therapists aren’t in-network with any providers.
There are two major types of insurance plans - HMO and PPO. Whether you have BCBS, Aetna, Cigna, or any other insurance, you will either have the HMO or the PPO version. There are many nuanced differences between HMO and PPO plans, but for our purposes, think of it like this: HMO plans only help you pay for therapy with in-network therapists, while PPO plans help you pay for therapy with any licensed therapist.
It Has To Be More Complicated Than That, Right?
A little bit! If you have a PPO plan and you see an in-network therapist, you will pay your therapist a small (typically $0 - $40) copay or coinsurance fee, and your insurance plan will cover the rest of the cost of the session, paying your therapist directly.
If you have a PPO plan and you see a therapist who isn’t in-network with your insurance, you will pay the therapist their full fee upfront. Afterwards, you’ll submit some paperwork to your insurance provider, and they will reimburse you a set percentage (usually 50% - 90%) of the therapist’s fee. Often, you will have to hit a deductible - in other words, this reimbursement will only kick in once you’ve spent a certain amount on therapy.
If you have an HMO plan, you can only use it to pay for in-network therapists. You will pay your therapist a small (typically $0 - $40) copay or coinsurance fee, and your insurance plan will cover the rest of the cost of the session, paying your therapist directly.
Those Reimbursement Ranges Are Kind of Large - What Will I Actually Pay?
The short answer is: it depends! Because the details are different for each plan, we highly recommend calling your insurance company to figure out how it will work in your case.
Before calling, it is important to know whether the therapist you are trying to see is a psychologist, social worker or mental health counselor. You should also know their zipcode, and the code they will classify your treatment under (for Sophia clients, the code is most often 90834, but you can always check with your therapist to make sure).
What Should I Ask The Insurance Company When I Call?
Here are five questions that you should make sure to cover with your insurance company.
Do I have an out-of-network deductible? If so, what is it?
Some insurance plans have deductibles, which means you have to pay the fee in full up to a specific amount until benefits kick in. The deductible normally resets annually. The next two questions will help you understand how much the insurance company will cover after a deductible has been met.
What is the allowable amount for an out-of-network provider for the CPT code 90834?
The allowed amount is the maximum amount on which payment is based for covered health care services. A CPT code is insurance-speak for the kind of service offered, in this case 50 minutes of psychotherapy. The allowable amount varies based on the credentials of your therapist (for example, the allowed amount is higher for a psychologist than a social worker or mental health counselor)
What is my copayment and/or coinsurance?
A copayment is a fixed amount you pay per session. Coinsurance is a percentage of the fee that you pay. This is illustrated in the example below.
How many sessions per calendar year are covered?
Some plans will cover an unlimited number of visits but others cap it at a certain number per year.
How do I file out-of-network benefits?
Do I Have Other Options?
Regardless of your plan, you can decide to pay out-of-pocket, without involving your insurance company. This means you will be responsible for the therapist’s full fee. We've written a blog post about why you might want to do this.
How Does Sophia Get Involved?
At Sophia, we only match people who are paying out-of-pocket, or using out-of-network benefits. We don’t interact with insurance providers, but we do make sure that if you want to use out-of-network benefits, you can do so. We charge people a matching fee to use our service, equivalent to the fee your therapist charges for a single appointment. Your Sophia therapist will waive the cost of your first Sophia appointment, so that there is no additional cost to you. Please note, however, that the Sophia match fee will not be covered by your insurance company's out-of-network benefits. For more information about why we’ve made these choices, please see our FAQ.
Honestly, This Would All Be Way Easier If You Gave Me An Example.
We thought you’d never ask! Here is an example of how a sample client's out-of-network insurance benefits work.
Joe signed up for Sophia, and was matched with a therapist he is excited to work with. Their free introductory call was great, and Joe booked an appointment. He wasn’t quite sure what his benefits looked like, though, so called his insurance company to ask about his behavioral health benefits. He first asked about his out-of-network deductible.
Joe learned his out-of-network deductible was $1000. This means Joe will cover the first $1000 of therapy expenses before his out-of-network benefits kick in.
Then, Joe asked "What is the allowable rate for out-of-network benefits for CPT code 90834?"
The call center representative asked him the zipcode of the provider, which Joe provided. He learned the allowable rate was $150 for a psychologist and $125 for a social worker.
Joe then asked about his coinsurance.
He learned his insurance company would cover 70% of the costs (up to the maximum allowable rate). So, for instance if Joe saw a psychologist who charged $200 per session, Joe would be reimbursed 70% of $150 (which is $105). Joe would need to cover the remaining $95 out of pocket.
Joe asked if there were any caps on the number of sessions per year.
He learned that under his plan, there were no caps. He also did not have to request prior authorization from his primary care provider for these visits.
Joe asked the call center representative how to file the paperwork.
The call center representative mentioned having to mail in the monthly "superbill" Joe would receive from his therapist. Keep in mind the Better app can help to reduce the hassle of filing out-of-network claims. If you use Better, all you have to do is take a picture of your bill. Learn more on their website: https://www.getbetter.co/
Keep in mind call center representatives are trained to discourage you from using out-of-network benefits! While it is certainly a hassle, using out-of-network benefits makes it possible to access quality therapists. The Better app can help to reduce the hassle of filing out-of-network claims.
Whew. That’s Over.
We know this can be complicated - please contact us if you have any questions!