Understanding Your Mental Health Insurance Benefits

At Virginia Beach Counseling and Wellness, your mental health and wellbeing are our top priority; however, we still have to tackle the topic of fees and insurance coverage.  Understanding your insurance benefits for mental health can be complicated, so we’ve put together a guide to answer some of the most common questions.  As always, we are here to help with any billing questions, but we want you to be as informed as possible about how insurance coverage works.

Common health insurance terms:

Copay:  This is a flat fee that you pay for a service and your insurance pays the remainder.  For example, you may pay a $25 co-pay and your insurance covers the remaining $100.  You may have to meet your deductible (explained below) before this becomes the only amount you have to pay.  Your co-pay is set by your insurance company and your provider is required to collect that amount.

Coinsurance:  This is similar to a co-pay, but it is a percentage, instead of a flat fee.  For example, you may have a 20% co-insurance.  Again, you may have to meet your deductible before this applies.  This percentage is established by your insurance company and your provider is required to collect it.

Deductible: This is an amount, set by your insurance company, that you are required to pay before the insurance will cover any of your claims.  You are responsible for paying the full fee for a service, until you meet your deductible.  For example, if your deductible is $500 and the fee for therapy is $100, you would be required to pay $100 for your first five therapy appointments (assuming you had no other medical claims).  After the first five appointments, your insurance company would begin paying a portion and you would have a co-pay or co-insurance.  You may have a separate deductible for mental health. You typically have choices about your deductible amount when selecting your insurance policy.  Providers who are in network with your plan are required to collect these fees.

Out of Pocket Max:  This is the maximum amount an insured person will pay for services before the insurance company begins paying all claims at 100%.

Explanation of Benefits (EOB) – This is the document that comes in the mail or is sent to you online, which explains your coverage for a specific service.  You will receive an EOB from your insurance company for each therapy appointment.  It will explain what your insurance covered and what you owe.  The insurance company also sends us a copy.  This is the first place you should look if you have questions about what you were charged for an appointment.

In-Network – This means we have signed a contract and agreed to work with your insurance company.  We have agreed to accept a discounted rate, known as the contracted rate, for our services.  We are in-network with most of the local insurance companies.

Out-of-Network – This means we have not contracted to work with your insurance company.  We have not agreed to the insurance companies discounted rates and you are responsible for our full fee.  In some cases, you may have out-of-network coverage, which means your insurance company will still pay for a portion of your fee, but probably at a lower rate than they would pay for an in-network provider.

Questions to ask your insurance company about your mental health benefits:

What is my deductible for in-network (or out-of-network, if we are not a part of your plan) mental health benefits?
What is my co-payment or cost-share for mental health services?
Does my co-payment or cost-share depend on the length or type of appointment?
Does my plan require a pre-authorization or referral for mental health services?
(NOTE- VBCW is a non-network provider with Tricare and may require a referral.  Be sure to tell Tricare you will be seeing a non-network provider)

In order to answer questions about fees, the representative may ask you which CPT code we will use for your service.  The following are our most commonly billed CPT codes:

90791 – intake assessment, this is always used for your first appointment and possibly for additional appointments
90837 – psychotherapy 53+ minutes (commonly referred to as 60 minutes)
90834 – psychotherapy 36+ minutes (commonly referred to as 45 minutes)
90847/90846 – family psychotherapy with or without the patient present

We know insurance benefits can be complicated to understand!  Please reach out if we can answer any other questions.