🧾 Understanding Your Mental Health Insurance Coverage
Restoration Counseling LLC | #RestorationCounselingDSM
Navigating insurance can feel overwhelming, especially when it comes to therapy and mental health care. At Restoration Counseling LLC, I believe knowledge is power — and understanding how your insurance works is an important step in advocating for yourself and your mental wellness.
This guide walks you through how insurance coverage works, common terms you’ll encounter, and questions to ask your insurance company before starting therapy.
🧠Mental Health Coverage Is Protected by Law
Under the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA), most health insurance plans are required by law to provide mental health and substance use coverage comparable to medical and surgical benefits.
This means your plan cannot legally apply higher copays, deductibles, or visit limits for mental health care than it does for physical health care.
However, the exact details — such as deductible amounts, coinsurance rates, and provider networks — can vary widely from plan to plan.
💳 Copay, Deductible, and Coinsurance — What’s the Difference?
Copay: A fixed dollar amount (like $25) you pay each session, often due at the time of service.
Deductible: The total amount you must pay out-of-pocket each year before your insurance begins contributing to your care.
Coinsurance: A percentage of the service cost (for example, 20%) that you pay after meeting your deductible.
Out-of-Pocket Maximum: The most you’ll pay in a year for covered services before your insurance pays 100%.
If you have a high-deductible plan, you’ll pay the full rate for therapy until your deductible is met. Once you reach your deductible, coinsurance and copay rates apply.
đź’ˇ Helpful Insurance Terms & Definitions
In-Network
Doctors, hospitals, clinics, and other providers who have a contract with your insurance company to offer services at a discounted or contracted rate.
Mental health providers are often considered in-network with certain insurance carriers.
Out-of-Network
Providers who do not have a contract with your insurance plan. You can still see them, but your costs may be higher and reimbursement is typically partial.
Deductible
The amount you pay for eligible services each benefit period before your plan begins to pay. The deductible does not include copayments, coinsurance, or non-covered services.
Example: If your deductible is $1,000, your plan won’t pay anything until you’ve paid $1,000 toward covered services (after discounts and adjustments).
Note: Some plans have separate deductibles for in-network and out-of-network care.
Types of Deductibles:
Individual Deductible: The amount one person on your plan must meet before coverage begins.
Family Deductible: Most family plans combine individual deductibles into a total family deductible. Once that amount is met, post-deductible coverage begins for everyone, even if individual deductibles aren’t fully met.
Copayment (Copay)
A fixed dollar amount due at the time of service (for example, $25). Many insurance cards list both specialist and primary care copay amounts.
Coinsurance
Your share of the cost of a covered service, usually a percentage (for example, 20%) of the allowed amount after you’ve met your deductible.
Some policies have a coinsurance maximum — the most you’ll pay in coinsurance each year before insurance covers 100%.
Example:
If the allowed rate for a session is $100 and you’ve met your deductible, your 20% coinsurance means you pay $20 and your plan pays $80.
Out-of-Pocket Maximum
The maximum amount you’ll pay in a plan year for covered services (including deductibles, copays, and coinsurance). After reaching this limit, your plan pays 100% of covered costs for the rest of the year.
Note: This does not include your monthly premium, non-covered services, or out-of-network charges beyond allowed amounts.
Preventive Care
Certain preventive services — such as physicals, vaccines, and screening tests — are fully covered without a deductible, copay, or coinsurance under the ACA. These services are typically non-diagnostic and paid at 100% by insurance.
This list is not exhaustive and is meant as a general guide. Clients are responsible for understanding their specific insurance plan. For personal details, call the member services number on the back of your insurance card.
🧾 Out-of-Network and Superbills
If your therapist is not in-network with your insurance, you can pay privately and request a superbill — a detailed receipt with the necessary codes for reimbursement.
You can then submit this to your insurance company to see if they’ll reimburse part of the cost.
When you call your insurer, ask:
Do I have out-of-network mental health benefits?
What percentage of session fees are reimbursed?
How do I submit a superbill for reimbursement?
How long does reimbursement typically take?
đź‘Ą Dual Insurance Coverage
If you have more than one insurance policy (for example, through your employer and a spouse), one plan is your primary coverage and the other is secondary.
The primary plan is billed first.
The secondary plan may cover the remaining balance.
Make sure both carriers know about your dual coverage to avoid claim delays.
đź“‹ Questions to Ask Your Insurance Company
Before beginning therapy, call the number on your insurance card and ask:
Does my plan cover outpatient mental health counseling (CPT 90837)?
What is my copay, deductible, and coinsurance?
How much of my deductible have I already met?
Do I need preauthorization for therapy?
Is there a limit on the number of therapy sessions per year?
Can I use a superbill if my provider is out-of-network?
Does my plan cover telehealth sessions?
Document the name of the representative, date, and what they tell you — this record can protect you if billing questions arise later.
🧍‍♀️ Choosing a New Insurance Policy? Key Things to Consider
When evaluating new health insurance plans, look for:
Mental health and therapy coverage included
Reasonable deductible and out-of-pocket maximum
Telehealth therapy benefits
Out-of-network reimbursement options
Flexibility to use HSA/FSA funds for therapy
Whether referrals or preauthorization are required
Plans with lower premiums often come with higher deductibles — so weigh your monthly cost against your typical medical and therapy needs.
❤️ my Commitment
At Restoration Counseling LLC, I want you to feel informed and confident about the financial side of your care.
I will gladly provide superbills, CPT codes, and guidance to help you verify your benefits. My goal is for you to focus on your healing — not the paperwork.
