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 Optum United 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.
The last time we spoke with Optum insurance regarding the out-of-network coinsurance reimbursement rate, we were told that they will cover 70% of their usual and customary rate or allowed amount (Optum sets this at $139 for a 45 minute meeting).
70% of the usual and customary fee (set at $139) means that they will pay $97 of the fee. After reimbursement, you would owe the difference between $97 and your therapist’s rate.
We have also seen out-of-network deductibles range from $500 - $1,000 depending on the plan.
To figure out your benefits, call the number on the back of your insurance card and ask to speak to a representative about your behavioral health benefits.
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.