Navigating Insurance Coverage for Mental Health

Insurance may seem like a confusing and at times frustrating way to pay for services.  However, with the passage of the  Mental Health Parity Act (2008),  many health plans are required to provide equally for mental health and substance abuse treatment.  This means a plan would cover visits for the treatment of depression the same as visits for high blood pressure. 

As insurance is based upon the medical model of care, therapy sessions must meet a standard known as "medical necessity."  This means that services are medically necessary to reduce distress and improve functioning.  Typically a diagnosis is required for treatment.  Therefore, services for the treatment of conditions such as depression, anxiety, Bipolar Disorder, etc. are likely to be covered.  Whereas, services that are not deemed medically necessary, may not be covered.  Examples of services that are not typically medically necessary include those that are solely for personal and/or relationship growth and development.  A few examples are career counseling, pre-marital counseling, consults, divorce mediation and some types of couples counseling.  The major take away is whether or not a service is covered depends upon the terms and conditions of the specific plan. Thus, it is always good to review your plan and check with your insurance provider first.  Here are a few helpful questions to ask your insurance provider:

  • Is this service (individual counseling, couple's counseling/outpatient in an office) covered?
  • Is this provider "In Network?"
  • Do I have "Out of Network" benefits? 
  • Does my deductible apply?  If so, what part of the cost is my responsibility?
  • Do I have a co-pay?  If so, what is it?
  • How many sessions are allowed?

What About Services That Are Not Covered?

For clients who wish to work on personal and/or relationship growth without any symptoms or behaviors that are distressing, this may seem discouraging.  However, private pay is an option for these types of services.  Private pay refers to the fees that are set by the therapist.  They can range depending upon the type of service, level of experience of the therapist and specialty of  the therapist.  Some therapists have sliding scales that offer a lower fee based upon certain criteria.  You may also be able to use your Health Savings Plan to cover private pay fees.