Insurance
Some clients will be able to use their insurance to pay part of their cost of services. Even when they are able to have their insurance provide benefits, some clients will still choose to not use their insurance because of some of the differences that are involved when insurance companies get involved. After giving you some information about this, we will explain what the possibilities are for using your insurance benefits either on an in network basis (when the clinician you are seeing has become a participating provider with both your insurance company and your particular plan) or on an out of network basis (where you submit claims to the insurance company). Please note that it is possible that your benefits for mental health may be handled by a different company than handles your other medical or health needs. It is your responsibility to check with your insurance company and to understand your benefits from them. You can then let us know about your insurance if you choose to use it and are able to for your sessions.
Insurance
Private Pay
A case manager and billing staff at the insurance company will be aware of your diagnosis and treatment plan.
Many mental health benefits are also contingent on periodic updates from your therapist.
Your therapy may become part of your permanent medical record.
Your case record is held by your clinician.
Information would only be released if legally required or you gave your consent.
Treatment is focused on the diagnosis and issues identified that relate to a medical model.
Your insurance company may have prefered ways of treating particular situations.
Treatment can cover a broader range of issues, not restricted to medical necessity.
Particular methods used in your treatment is determined by you and your clinician.
Insurance companies generally only provide benefits when couples therapy can be useful in helping one or both partner's mental health.
Couples therapy is viewed through the lens of one or more "identified patients".
Generally, insurance will not cover treatment focused on developing skills and patterns to prevent future problems when the partners are not yet being affected.
Issues in the relationship can be viewed without having to see how they are affecting the individual partners' mental health.
The clinician can view and document what is going on through the lens of both partners as well as the relationship.
Some forms of couples therapy can be engaged in without having to determine "medical necessity", such as pre-marital counseling when problems have not yet been felt.
Insurance companies can deny continued coverage for treatment if they feel it is not medically necessary or if they do not feel adequate progress is being made.
At some point, a case manager from the insurance company may become involved to evaluate if longer term treatment should be allowed under your insurance plan.
You and your therapist are the only judges of whether it makes sense to continue paying for therapy.
Factors used to decide about whether therapy is being effective can be broader than the medical criterion that insurance companies utilize.
Claims will include diagnoses (or diagnostic impressions) and these are stored by insurance companies in databases.
A record of certain mental health diagnoses or treatment can be taken into account in future decisions. For example, some life insurance companies have denied to issue policies based on particular mental health history. Historically, the same has held true for some employement decisions.
Diagnoses (or diagnostic impressions) are not submitted to your insurance company and remain in the records maintained by your clinician.
In situations where a history of a mental health diagnosis or treatment could have an adverse effect in the future, you are likely to be directly asked about it. Being dishonest about it can also have serious consequences.
If you are using in network benefits, the clinician will submit the claim to your insurance company. You will just pay the portion that you are responsible for at the time of your session.
If you are using out of network benefits, you will have to submit a claim to your insurance company for reimbursement. You will pay the full fee at the time of your session and may get money back from the insurance company.
You will pay the session fee at the time of your session. You will not have to deal with the insurance company.
If you have access to a FSA/HSA (or another way of setting aside pre-tax dollars for health care expenses), you can use this for your payments. Depending on your tax bracket, this could save you approximately 25% of the cost of your treatment. Using these funds could be as easy as using a debit card or may require submitting a claim to the company administering your account.
Tends to be lower, however this will vary depending on your deductible, your copays, your coinsurance, and your out of pocket maximums as well as the contracted rate the insurance company has with your clinician.
Out of network costs tend to be more expensive than in network costs, for most health plans.
Costs may not be consistent across sessions.
Your session costs wil be fixed, but will generally be higher than they would be if you were using insurance.
Some clinicians have full fees that are less than what you would be responsible to pay if you were seeing a different clinician using your insurance.
There may be special programs that will help you with the cost of your treatment.
To use in network benefits, you can only see clinicians that are in network with your insurance company and your particualr insurance plan.
To use out of network benefits, you can only see clinicians that are acceptable for your plan (often excludes emerging clinicians) and you have to comply with whatever your plan requires for you to see an out of network provider, if they allow it at all.
You are free to select any provider that is legally allowed to practice based on who you think you will work well with.
Just because you are not using insurance does not mean that licensing laws governing treatment across state lines does not apply. You and your clinician still have to comply with these laws.
If you decide to use your insurance, it is important to tell us about all insurance policies that cover you, if there are more than one. This is because the insurance companies decide which policy is primary and claims have to be submitted to them first. Only then will the company of the secondary policy determine what they will cover from what the primary policy’s company did not cover. If it is done the other way and a claim is first submitted to the secondary policy’s company, then they could deny the claim or if they provide a benefit they might reverse that decision later. If they reverse payment later, it might be too late to submit a claim to the company of the primary policy. This would then make you responsible for the full cost of your sessions.
Using your insurance benefits can help reduce your out of pocket costs for therapy. If you decide to use your insurance benefits, you may be interested in learning how your benefits will apply, including how much benefit you will obtain from them. We would like to give you some guidance about this as you prepare to look at your particular situation and consult with your insurance company.
In Network Coverage
If you are using insurance and seeing a clinician who is in network with your insurance plan, it is important to understand how your insurance works. While Seeking Shalom will submit claims to your insurance company, it is important that you understand what your insurance covers and what will be your responsibility. You will need to talk to your insurance company to get the information you need to know about your coverage for mental health care. We can give you some guidance, but the ultimate decision around these comes from your insurance company. In planning for your out of pocket costs, here are the what the insurance company may make you be responsible for:
As long as your insurance company considers your clinician to be in network with your plan and accepts your claim as an in network claim, you will not be responsbile for the amount of your session fee that exceeds the contracted rate that has been set between your insurance company and our practice. These contracted rates can vary from practice to practice and from clinician to clinician, even for the same service.
If you have a deductible in your insurance plan, the first question to determine is whether or not you have to meet this deductible for mental health care. Some insurance policies do not require you to meet the deductible before other benefits for mental health care kick in, while other insurance policies may have dedcutibles that are very high without much chance of you meeting it. Paying for other healthcare may reduce the amount of deductible that you have to meet. If you are on a family plan, there may also be a family deductible (higher than the individual deductibles) that once met may mean that you do not have to meet individual deductibles. Until you have met your deductible, if you have one, you will be responsible for paying the full contracted rate each session.
Once you meet your deductible, you are likely to have to pay either a copay or coinsurance for each session. A copay is a fixed amount (like $25 or $60) that you pay for each session. In contrast, if you have to pay coinsurance, it is a percentage (like 20% or 50%) of the contracted rate for the session. Generally, more expensive insurance plans have lower copays or coinsurance, but there are exceptions to this. Some health plans require you to pay both a copay and coinsurance. Your insurance company can best guide you about this.
Once you have reached an out of pocket maximum for the year (which counts some but not all of your expenses), then the insurance company will usually pay the full contracted rate and you will not be responsible for payments for your sessions, although you may still be responsible for additional charges (such as fees for not showing for your session or requesting written reports). This out of pocket maximum, like the deductible, may be reached if you have a lot of other expensive medical procedures done during the year.
The following table will help you identify whether your provider is in network with the appropriate company. Remember that even when they are in network with the company that your insurance policy is with, you still need to determine whether they are in network with your particular plan.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers. Many Aetna members have good out of network benefits.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
Blue Cross Blue Shield companies cooperate with each other. Those whose plans are not tied to a particular network of providers (such as those with the “suitcase” icon on their cards) are able to visit providers from other Blue Cross Blue Shield companies. Our clinicians who are in network are in network with Empire Blue Cross Blue Shield. Through that status, they can be considered in network for people who have coverage through other Blue Cross Blue Shield companies.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher, Diana
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher, Diana, Jennifer
Out of network benefits may be possible for other providers.
In addition to benefits through their health insurance, some people will have short term benefits through their employer through a program called an Employee Assistance Program. These are generally limited to a small number of sessions to either work on a short term problme or to assess what you need and provide a referral.
We have clinicians that participate with a number of EAP programs. In order to access these benefits, you should first reach out to the company with whom your employer has contracted.
Out of network benefits are generally not permitted through an EAP, but there have been times when we have accepted a single case agreement to work with someone who has specifically asked to work with us.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
Most Medicaid beneficiaries in New York recieve their mental health care through a Managed Care Organization (which is administered by insurance companies that are listed separately). Very few Medicaid beneficiaries receive mental health coverage through Regular Medicaid directly from New York State.
In order for our emerging clinicians to be able to see Medicaid beneficiaries at a very reduced rate through the Journey to Peace program, New York State requires their supervisors to not accept any Medicaid plans as an in network provider. We believe providing service where there is a shortage of providers is more imporant and thus have followed these rules made by the state.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
Current federal rules do not allow mental health counselors or marriage and family therapists to be credentialed as Medicare providers. If you feel that this should change, please contact your federal legislators.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers, especially for those who have Medicare Advantage or Medicare Supplemental plans.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
Military One Source is the EAP for members of the military and their families. Unlike civilian EAPs, authorizations for non-medical counseling through Military One Source can be for up to a dozen sessions.
In Network:
– Christopher (credentialed for in person, video, telephonic and synchronous chat sessions)
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– Christopher
TRICARE does not provide out of network benefits except to approved out of network providers, so TRICARE benefits are not available when seeing other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
In Network (at least some plans):
– No Clinicians
Out of network benefits may be possible for other providers.
When determining information about your coverage, you may want to use our “Insurance or Third Party Payor” form when you are talking with your insurance company.
Out of Network Coverage
If you are using insurance on an out of network basis, you will be paying the full fee at the time of your session and submitting claims to your insurance company who may reimburse you for some of the expenses you have paid. In this case, it is important that you talk with your insuracne company in advance to understand what benefits they will give you. This includes making sure that your insurance company will provide benefits for the services that you are wanting to recieve with the clinician that you want to work with.Once you have determined that you have coverage, here are the costs that you may expect to have to meet:
Using out of network benefits, you will be responsible every session for the difference between your session fee (which you will be paying at the time of your session) and the UCR (“usual and customary rate” that may or may not have any relationship to real rates) the insurance company specifies the service you received. Insurance companies may not let you know their UCR before you begin submitting claims but it does become the basis for them calculating what they will pay for the out of network care you receive. It is unlikely that the UCR will be higher than your session fee, but if it is then the insurance company will use your session fee instead of the UCR in determining your benefits.
If you have a deductible in your insurance plan and the deductible applied to mental health care (which sometimes does not apply), you will want to determine what it is for out of network services. Usually, the out of network deductible is higher and out of network expenses will not count towards your in network deductible. You will be responsible for paying the full UCR (thus the full session rate) for your session, while you still have an out of network deductible to pay. Just the amount of the UCR for the session will be applied to reduce the amount of deductible you still have to pay towards future sessions. Just as with in network coverage, other out of network healthcare expenses may reduce the amount of deductible you still have to meet.
Once you meet your deductible, you are likely to have to pay either a copay or coinsurance for each session. A copay is a fixed amount (like $25 or $60) that you pay for each session. In contrast, if you have to pay coinsurance, it is a percentage (like 20% or 50%) of the UCR for the session. The insurance company will then reimburse you the difference between the UCR and the copay/coinsurance. Generally, copays and coinsurance are higher when using out of network benefits, so make sure you get the insurance company to give you the ones that apply to out of network healthcare. Some health plans require you to pay both a copay and coinsurance.
Once you have reached an out of pocket maximum for the year (which counts some but not all of your expenses), then the insurance company will usually pay the full UCR each session but you will still be responsible for the amount that the session rate is above UCR. This out of pocket maximum may be specific to out of network services and may be higher than your in network out of pocket maximum. Regardless, the out of pocket maximum may be reached if you have a lot of other expensive medical procedures done during the year that count.
Insurance or Third Party Payor Form
This form is available for our clients inside our client portal. We are offering this here to help you in exploring these questions with your insurance company.
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P.O. Box 685, Harrison, NY 10528