Is Therapy Covered by Insurance? And Other Questions

If you’re interested in therapy, either for yourself, your teen, or your family as a whole, one of the first questions you should ask is how you want to pay for it.

Is therapy covered by insurance? The answer is yes, sort of. Most plans will cover mental health services, including therapy, psychiatry, inpatient stays, and medication in some form.

While this is good news for those struggling with mental illness, how to use your benefits can get a bit complicated. If you want to use your insurance for therapy for your teen, you need to make sure to find someone who is covered by your plan. However, using insurance does come with some drawbacks, which are discussed in the last section.

Using HMO Insurance to Cover Therapy

If you have an HMO, your teen’s therapist will need to be “in network,” usually meaning they are in the same medical group as the rest of your teen’s doctors. You may also need a referral from a primary care physician.

Some medical groups don’t have their own mental health providers, in which case your teen will be referred to an outside group that accepts insurance. We’ve found this to be true of several of the bigger medical groups in San Diego.

Using PPO Insurance to Cover Therapy

If you have a PPO, your teen has a few more options. For the most coverage, they will still need to see an in-network provider. However, if your teen has a diagnosable mental health condition, you may be able to get partial coverage for out-of-network providers. Usually out-of-network providers require you to pay up front, and then you can submit your receipt (called a superbill) to your insurance for reimbursement.

PPOs give you more flexibility, but be aware that out-of-network care is often subject to its own deductible (the amount you have to pay before coverage kicks in), and the coverage may be lower than for in-network providers. For example, your plan may only cover 60% of the cost of out-of-network care (after the deductible), but 80% of in-network care (again, usually after a deductible).

How to Know What Insurance You Have and What It Covers

If you have health insurance through an employer, you should receive all of your plan information on a yearly basis during open enrollment. The paperwork you receive should tell you whether you have any deductibles, which services are covered at what percentage, and if there are any limits to your coverage.

If you have coverage through Covered California or a similar state exchange, you should receive a similar break down of costs when you go to enroll.

Regardless of how you get your insurance, if you think you are going to have mental health expenses in the coming year, including therapy for your teen, it’s worth taking a serious look at your insurance options during open enrollment. Sometimes the plans with a cheaper monthly premium are actually more expensive when you start factoring in weekly therapy visits and so on.

If you’ve looked at your enrollment paperwork and still have questions, call the customer service number on the back of your membership card. For mental health benefits, you may need to ask for the behavioral health department. Just know that sometimes even the customer service associates get confused, so it’s important to make sure that what they tell you lines up with what you’re seeing in your enrollment paperwork.

Other Types of Mental Health Coverage

If your teenager or other family member is struggling with a serious mental health condition like depression, bipolar, or ADHD, you may need more intensive mental health services, including psychiatry or inpatient services.

Here are a few things to keep in mind:

• Psychiatric medications like Prozac are covered under your prescriptions benefits. You should be able to fill psychiatric medications just like anything else. Some plans have a prescription deductible, and most will require a copayment. Generic medications are almost always cheaper.

• If your teenager is prescribed a brand name medication and the copayments are extremely high, check if the manufacturer has a copay savings program. The manufacturers of these expensive medications get most of their revenue from the insurance companies, so it’s in their interest to keep your copayment low so your teen stays on the medication. With a copay savings program, you may be able to signficantly reduce or even eliminate your copayment.

• Psychiatry should be included in your plan. Psychiatry appointments are typically covered as a specialist visit, so the copayment may be higher than for your primary care physician (PCP). While your PCP may be able to perscribe some psychiatric medications, we always recommend going through a psychiatrist. They have the benefit of medical school plus additional psychiatric training, and as specialists they are much more aware of medication options, side effects, diagnoses, etc.

• Sometimes, especially if your teen is suicidal or self harming, you may need to look into inpatient services. Insurance usually covers mental health inpatient services just like they would any other hospitalization. There are several inpatient facilities in San Diego, all of which to our knowledge are in-network with the major insurance companies. To initiate an inpatient stay, you may need to go to the ER or (for readers in San Diego) call the Psychiatric Emergency Response Team (PERT) via 911. Both the ER and PERT will connect you to social workers who can help you verify that a particular facility takes your insurance.

Using Insurance with the Teen Counseling Center of San Diego

The Teen Counseling Center of San Diego is part of Integrity Counseling Group, a group practice with offices in Carlsbad, San Marcos, and Mission Valley. As such, we are out-of-network with all insurance companies.

This means that our services must be paid for by the client. If you have a PPO, however, you may be able to be reimbursed for part of the cost (see the PPO section above).

We made the decision not to accept insurance for several reasons. Primarily, we believe in providing our therapists with a high quality of life. We also want to provide you and your teen with the best therapy experience possible.

Insurance pays very little per therapy session, so groups that take insurance often have to load their employees up with clients in order to pay them a liveable wage.

This often leads to more stress for therapists and even burn out. As you can imagine, talking to people about their mental health 8 hours a day, 5 days a week, gets pretty exhausting. And that doesn’t even include paperwork, returning client calls, etc.

At the Teen Counseling Center of San Diego, our therapists see about 5 clients a day. This allows them to be “on” for each client and deeply engaged in the conversation. It also gives them more time in between sessions to regroup and get paperwork done.

While this model is more expensive for the client, we have found that our teen clients and their parents appreciate the high quality of care we provide as a result. We also are able to give our clients the same time slot each week, and there isn’t a wait to get in.

One other thing to note about insurance is that you can only use it if you have a diagnosable health condition. If your teen doesn’t meet the clinical definition for mental illness, or if you would prefer not to have a diagnosis in their medical record, paying out of pocket is probably your best option anway.

For more information about the Teen Counseling Center of San Diego or to meet our therapists, please visit our About page. As always, we are here to serve you and your family. If you would like to set up an appointment for your teenager, please call our intake specialist at (760) 283-7000.