Is Couples Therapy Covered by Insurance?
The very short answer: sometimes! If you have an HMO plan, couples therapy will not be covered by insurance if you choose to work with me as I am an out-of-network provider. If you have a PPO plan, you are likely eligible for full or partial reimbursement. If you plan to seek reimbursement from insurance, you will need to have a diagnosable condition. To learn more, read on.
If I have an HMO plan, how much is covered?
If I have a PPO plan, how do I find out how much is covered?
How does my deductible factor into coverage for couples therapy sessions?
How do I get reimbursement for couples sessions if I have a PPO plan that covers all or partial fees?
Why is couples therapy reimbursed less than individual therapy?
Can I use my HSA card to pay for sessions?
What diagnosable conditions do you use for couples sessions when neither person has a mental health disorder?
If I have an HMO plan, how much is covered?
If you opt to work with a couples therapist who is in-network with your insurance plan, you are only responsible for the co-payment tied to “behavioral health services.” This will be the same co-payment for individual therapy or any other type of psychotherapy.
One note of caution: though working with an in-network provider for couples therapy seems like a better investment, these clinicians are often primarily treating individuals and not highly trained or seasoned couples therapists. If you are seeking more preventative services (such as premarital counseling in the absence of any major issues) or only need help with minor conflicts or points of tension, working with an in-network provider may still be a good option if finances are tight.
If I have a PPO plan, how do I find out how much is covered?
PPO plans will cover couples or family therapy under the “90847” code about 99% of the time. I have yet to work with a couple that didn’t get some reimbursement back from their specific plan (especially if you have a BCBS or any other major health insurance plan). When you call your plan’s behavioral health line specifically ask “how much is covered for the 90847 code?”
The rep will give you one of two answers: X% of the provider’s rate or X% of the “allowable amount.” If you hear the latter, make sure to ask what the “allowable amount” is as this will likely be much lower than the provider’s rate. For example, if the rep shared that 80% of the “allowable amount” is covered and the max allowable rate is $200, then you will get $160 in the form of a check or direct deposit.
How does my deductible factor into coverage for couples therapy sessions?
Most of the time, your plan will require that you meet your deductible before any coverage applies. If your plan only covers the “allowable amount” then a small percentage of my overall fee will go towards your deductible.
How do I get reimbursement for couples sessions if I have a PPO plan that covers all or partial fees?
Submitting claims should be relatively easy. At the end of each month, I generate what is called a “superbill” that has all the information insurance needs in order to process reimbursement. You will log into your TherapyNotes portal account, download this form, and then log into your insurance provider’s account and follow instructions for how to submit claims. 99% of my clients have had zero issues with this process. Some insurance companies (pending the representative) will require additional information on the form, which I’m happy to modify once the request is made.
Can I use my HSA card to pay for couples therapy?
Yes! You can pay using your HSA card even if you are not using insurance to get reimbursement.
What diagnosable conditions do you use for couples sessions when neither person has a mental health disorder?
If one or both partners are also seeing individual therapists, I try to match the diagnosis that is used for individual therapy in order to remain consistent with professional records. If neither of you are seeing an individual therapist and do not have any symptoms of anxiety, depression, or other mental health related issues that merit a formal diagnosis, I will often use two codes simultaneously that most insurance companies will provide reimbursement for:
· F43.20 Adjustment disorder, unspecified
· Z63.0 Problems in relationship with spouse or partner