What Insurance Covers Mental Health Therapy?

Cost is a concern for mental health services, but fortunately, health insurance plans are available, including in-network and out-of-network options. Find out how they can make care more affordable and learn about BlueCrest’s comprehensive coverage options.

Key Takeaways

• Mental health care can be expensive, but insurance plans are available.
• Various plans cover different aspects of mental health care, including therapy, assessments, and medications.
• Both in-network and out-of-network insurance plans offer benefits. In-network plans have more controlled costs, while out-of-network plans provide more flexibility.

Table of Contents

• What is the Mental Health Parity and Addiction Equity Act (MHPAEA) and How Does It Ensure Coverage?
• What Does Insurance Typically Cover for Mental Health and Substance Use Treatment?
• In-Network vs. Out-of-Network Coverage: What Are the Key Differences?
• How Do Out-of-Network Benefits Work? A Step-by-Step Process
• Why Does BlueCrest Counseling Operate Out-of-Network?
• What Questions Should I Ask My Insurance Provider?
• BlueCrest Works with Most Insurance Plans
• FAQs

Introduction

Mental and behavioral health services can be pricey, but insurance coverage is available. Thanks to the Mental Health Parity and Addiction Equity Act (MHPAEA), individuals can access coverage as they would for any other health condition, but plans vary, and it’s important to understand what you may be eligible for.

BlueCrest Counseling of New Jersey works as an out-of-network provider for mental and behavioral health services. We will verify your insurance in advance and explain exactly what’s covered before you begin treatment. This article provides insight into what to expect.

What is the Mental Health Parity and Addiction Equity Act (MHPAEA) and How Does It Ensure Coverage?

The MHPAEA of 2008 ensures individuals can access mental health benefits through insurance as they would for any other health condition. It doesn’t force insurers to offer coverage for mental health services, but if they do, that insurance must be on par with physical health coverage. While there are no stats specifically citing how the Act has increased access, a PubMed study reveals it significantly lowers costs, a main access barrier.

The MHPAEA applies parity requirements across three main areas:

• Financial Requirements: Copays, coinsurance, deductibles, and out-of-pocket maximums for mental health care can’t be more restrictive than those applied to medical/surgical care.
• Quantitative Treatment Limitations: Annual visit limits or day limits must also be comparable.
• Nonquantitative Treatment Limitations: A broader category that includes prior authorization requirements, network adequacy, and geographic or facility-type restrictions. The regulation provides that all plan standards that limit the scope or duration of benefits for services are subject to the nonquantitative treatment limitation parity requirements. This includes restrictions such as geographic limits, facility-type limits, and network adequacy.

The Affordable Care Act (ACA) of 2010 also played a role in expanding who the parity rule applies to and, in many instances, requiring mental health coverage to exist in the first place.

What Does Insurance Typically Cover for Mental Health and Substance Use Treatment?

Insurance typically offers mental and behavioral health benefits, including individual and group therapy, family therapy sessions, medication, diagnostic assessments, and telehealth, as follows:

• Individual Therapy: Often focuses on proven behavioral health treatments, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and motivational interviewing (MI).
• Group Therapy: Individuals attend group therapy sessions to improve mental health, reduce isolation, learn from their peers, and practice coping skills in real life.
• Family Therapy: Families are often brought into therapy sessions so they can better understand their loved one’s mental health condition and ensure they provide a supportive environment.
• Medication Management: Medications are often used to reduce cravings and withdrawal symptoms and ensure ongoing emotional regulation.
• Diagnostic Assessments: Many health insurance plans require a formal mental health diagnosis to cover treatment. These occur at the beginning of treatment and are typically ongoing, ensuring that therapeutic and medical approaches are suited to the client’s needs.
• Telehealth: Virtual visits expand access and are typically covered by health plans.

In-Network vs. Out-of-Network Coverage: What Are the Key Differences?

In-network and out-of-network coverage differ in payment structures and what you’ll pay for therapy.

In-Network Providers

Therapists have signed a contract with your insurance provider, agreeing to accept a negotiated rate for their services. The client will pay a small, fixed copay or coinsurance amount, and the insurer pays the provider directly.

Out-of-Network Providers

These mental health providers have not signed a contract with your insurance plan. As a result, the payment structure works differently, as follows:

• You typically pay the full session fee upfront, at the time of service
• Your insurer reimburses you afterward for a percentage of the cost
• That percentage is based on your insurer’s “usual and customary rate” (UCR) for the service in your area, not necessarily your provider’s actual fee
• Out-of-network care is usually subject to its own deductible, which is often separate from (and higher than) your in-network deductible

While both in-network and out-of-network systems provide advantages, research published in AJMC reveals people in need of medical care are 3.5 times more likely to choose an out-of-network plan.

PPO vs HMO

Your plan type dictates your out-of-network coverage, as follows:

• PPO (Preferred Provider Organization) plans typically include out-of-network benefits, giving you the flexibility to see providers outside the network and still receive partial reimbursement
• HMO (Health Maintenance Organization) plans generally do not offer out-of-network benefits — if a provider isn’t in-network, the plan typically won’t reimburse for their services at all (outside of emergencies)
• POS (Point of Service) plans often fall in between, offering some out-of-network coverage depending on the specific plan

How Do Out-of-Network Benefits Work? A Step-by-Step Process

With out-of-network benefits, you will need to verify your benefits, pay for your sessions up front, receive a superbill, file a claim, and wait for reimbursement. Here’s how the process works, step by step:

1. Verify Your Benefits: Check your plan’s benefits description for details on mental health coverage. Start by calling your insurance provider to find out whether you have out-of-network coverage, your out-of-network deductible, the reimbursement percentage, and any visit limitations.
2. Pay for mental health treatment up front.
3. Receive a superbill: This will include the provider’s name, license number, diagnosis code, procedure, service code, date of service, and fees charged.
4. Submit the Claim: Submit the superbill to your insurer for review – typically through an online portal.
5. Wait for Processing: Your insurer will apply your out-of-network deductible, then reimburse a percentage of their ‘usual and customary rate’ for the service. Processing typically takes a few weeks, and reimbursement is issued by check or via direct deposit.

Why Does BlueCrest Counseling Operate Out-of-Network?

BlueCrest Counseling offers out-of-network services because they provide clinical freedom, greater privacy, more provider choices, and no insurer-imposed session caps.

• Clinical Freedom: Without a contract dictating covered services, session limits, and treatment protocols, our mental health professionals can offer a more personalized approach.
• No Insurer-Imposed Session Caps: Out-of-network providers aren’t subject to session caps that can impede comprehensive care.
• Greater Privacy: In-network providers must share diagnostic and treatment details with insurers as part of claims processing. Out-of-network practices generally only share what the client chooses to submit via a superbill.
• Provider Choice: Clients can choose providers based on specialization and fit; they are not limited by their network options.

What Questions Should I Ask My Insurance Provider?

Before starting treatment for a mental health disorder, ask your provider questions about your deductible, out-of-pocket costs, reimbursement, and payment structure. Here are some topics to inquire about:

• Do I have out-of-network mental health benefits? – Typically, your plan type will indicate whether you have in-network or out-of-network benefits, but it’s best to confirm this with your provider.
• What is my out-of-network deductible, and has it been met?- Your deductible is the amount you have to pay out of pocket before your insurance starts paying its share.
• What percentage of the session fee will be reimbursed?- A strong indicator of how much you’ll pay.
• Is a superbill sufficient for reimbursement, or do I need pre-authorization? Some insurers may require pre-authorization for covered services.
• Are there session limits per year?- Indicates how much care your plan will cover.

BlueCrest Works with Most Insurance Plans

BlueCrest Counseling of New Jersey keeps care affordable by working with most major insurance plans, including Aetna, UMR, Cigna, United Healthcare, and Humana. We offer a no-obligation insurance verification process before treatment begins, so you know exactly how much you’ll pay.

Once treatment starts, we provide optimal support with comprehensive care for mental health issues, behavioral health conditions, and substance abuse disorders, ensuring optimal well-being. Care is provided across various levels of outpatient services, meeting clients where they are in the recovery process.

Contact us to learn more about our extensive services and disorder treatment.

FAQs

Do insurance companies cover mental health services?

Yes, many insurance plans cover mental illness and behavioral health care. The MHPAEA requires health plans to offer mental health benefits comparable to medical services and surgical benefits in terms of costs and limits. The ACA also requires most individual and small-group plans to cover mental health as an essential health benefit.

What’s the difference between in-network and out-of-network therapy coverage?

In-network providers have a contract with your insurer, so you pay a small copay, and the insurer bills the provider directly. Out-of-network providers don’t have that contract, so you typically pay the full fee upfront and submit a claim for partial reimbursement afterward.

Does my plan have out-of-network mental health benefits?

It depends on your plan type. PPO and POS plans typically include some out-of-network coverage. HMO plans generally do not, except in emergencies. The best way to confirm is to call the member services number on your insurance card and ask specifically about out-of-network behavioral health benefits.

What is a superbill?

A superbill is an itemized receipt your therapist provides after each session (or monthly) that contains everything your insurer needs to process a reimbursement claim, including provider information, diagnosis code, procedure code, dates of service, and fees paid.

How much will I get reimbursed for out-of-network therapy?

The reimbursement amount varies by plan. Your insurer calculates reimbursement based on their “usual and customary rate” for the service in your area, not necessarily your provider’s actual fee, after your out-of-network deductible is met. Ask your insurer directly for your plan’s specific percentage.

Sources

• Centers for Medicare & Medicaid Services (CMS). “The Mental Health Parity and Addiction Equity Act (MHPAEA).” https://www.cms.gov/marketplace/private-health-insurance/mental-health-parity-addiction-equity
• U.S. Department of Health and Human Services, Department of Labor, and Department of the Treasury. “Requirements Related to the Mental Health Parity and Addiction Equity Act.” Federal Register, September 23, 2024. https://www.federalregister.gov/documents/2024/09/23/2024-20612/requirements-related-to-the-mental-health-parity-and-addiction-equity-act
• Employee Benefits Security Administration (EBSA), U.S. Department of Labor. “Statement of U.S. Departments of Labor, Health and Human Services, and the Treasury Regarding Enforcement of the Final Rule on Requirements Related to the Mental Health Parity and Addiction Equity Act.” https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-parity/statement-regarding-enforcement-of-the-final-rule-on-requirements-related-to-mhpaea
• Centers for Medicare & Medicaid Services (CMS). “Medicaid: Parity.” https://www.medicaid.gov/medicaid/benefits/behavioral-health-services/parity