We have worked with many clients and their insurance companies to help cover the cost of therapy. Here is an example of how out-of-network insurance benefits can be applied:
If you have AETNA insurance, you most likely have out-of-network benefits. You also mostly likely do not need pre-approval for a 45 or 60 minute psychotherapy session, and there is no limit to the amount of sessions you can have in a year.
Open Access Commercial PPO
The last time we spoke with AETNA insurance regarding the out-of-network coinsurance reimbursement rate for Open Access Commercial PPO, we were told that they will cover 70% of the usual and customary rate or allowed amount ($300 for a 45 minute meeting, and $375 for a 60 minute meeting).
Here’s an example of what this looks like using the Fair Health Consumer website to calculate expenses for a 45-minute session. This is a useful tool to provide you with an estimate of your healthcare expenses.
70% of the usual and customary fee means that they will pay $210 of a $300 fee, making the out of pocket cost $90 after reimbursement.
Choice POS II
The last time we spoke with AETNA insurance regarding the out-of-network coinsurance reimbursement rate for Choice POS II, we were told that they will cover 60% of the usual and customary rate or allowed amount ($300 for a 45 minute meeting, and $375 for a 60 minute meeting).
Here’s an example of what this looks like using the Fair Health Consumer website to calculate expenses for a 45-minute session.
60% of the usual and customary fee means that they will pay $180 of a $300 fee, making the out of pocket cost $120 after reimbursement.
We have also seen out-of-network deductibles range from $2,250 - $3,000 depending on the plan.
To figure out your benefits, call 888-702-3862, and ask to speak to a representative about your behavioral health benefits.
Be prepared to ask them these questions, fill out this form, and we will call to cross verify your benefits on our your behalf.
AETNA Payer ID for electronic submissions is 60054.
The claims address to mail in insurance claims for a PPO is:
P O Box 981204
El Paso, TX 79998-1204
Not sure of what some of these terms mean? Here is a quick glossary:
Allowed Amount: Or “negotiated rate,” is the maximum amount that your insurance company will pay for a covered service based on your plan. If the allowed amount your plan pays for mental health services is $100, for example, and your therapist charges $125 per session, you would be responsible for paying $25. This is also know as "Balance Billing.”
Deductible: This is the amount you have to pay for health care services before your insurance begins any reimbursement. So for example, let’s say your insurance covers 50% for each psychotherapy session, but only after you reach a $1,000 deductible. If each session is $200, you would have to pay for 5 sessions before you reach your deductible ($200 per session x 5 sessions = $1,000). In this case, after reaching your deductible your insurance would reimburse $100 (50% of $200) and you would be responsible for a $100 balance.
Point of Service (POS): A plan where you pay less to see a health care providers in the plan’s network. This plan requires that you obtain a referral from your primary care physician (PCP) to see a specialist.
Preferred Provider Organization (PPO): Like a POS plan, a PPO plan allows you to pay less to see a health care provider in the plan’s network. You may also see an out-of-network provider under this plan without needing a referral, but for an additional cost.
UCR (Usual, Customary, and Reasonable): This is the amount paid for services based on your geographic location. For example, in New York City, the UCR rate for out-of-pocket psychotherapy is typically between $200 and $300.
For a more comprehensive list, please see our full Glossary of Insurance Terms on the Rates & Insurance page.