1. Check your out-of-network benefits
These are typically in the Summary of Benefits, included in a member information packet or on your insurance company website. Keep an eye out for these terms:
Let’s say your out-of-network deductible is $1,000, and your insurance company pays for 100% of services after you meet that amount. That means you’ll have to pay $1,000 out of pocket, after which you’ll have “met your deductible.”
In this scenario, if you spend $1,500 on therapy services, you’ll have to pay $1,000 out of pocket (e.g. $100 at each session for 10 sessions), but a portion of the remaining $500 will be reimbursed to you in the form of a check (mailed to you after you submit your claim). Deductibles reset every calendar year, and any health expense you pay out-of-pocket contributes to meeting it.
Let’s say your therapist charges $100 per session. If your coinsurance is 25%, you’re only responsible for paying $25. Just remember that this comes in the form of a reimbursement: you’ll need to pay the full $100 upfront, then your insurance will send you a check for $75 after the session, once you’ve met the deductible and submitted a claim.
Some insurance companies determine an “allowed amount,” which caps the session fee that they’ll cover. If your insurance has determined $100 is their “allowed amount” per session, at a 25% coinsurance rate, your insurance company will still only reimburse you up to $75, no matter what the therapist’s session fees are. In other words, if your insurance has an allowed amount of $100 but your therapist’s session fees are $200 per session, you won’t get reimbursed more; you’ll still be reimbursed $75, and will be ultimately responsible for $125.