With all of the insurance changes coming in the New Year, we wanted to provide you with a summary of how insurance benefits typically work. The following are useful definitions for you to use when finding out your coverage for 2014.
In-Network Providers: Some licensed therapists (LMHC’s) sign contracts with insurance companies to provide services and are reimbursed by insurance companies at a fixed rate. These contracted therapists are called “In-Network Providers”. Insurance companies prefer that you use In-Network Providers. The contracted reimbursement rates are typically much lower than the rates most LMHC’s charge for services.
Out-of Network Providers: Many insurance companies will also reimburse if you receive services from an “Out-of-Network” Provider. This reimbursement works differently, as there is no contracted reimbursement rate. Insurance companies will typically reimburse either a set amount (for example, $65/session, no matter the cost of the session) or a percentage of the session cost (for example, 50% of the amount billed). You are then responsible for paying the difference between what the therapist charges ($100/session, for example), and what the insurance company reimburses (for example, 50%, or $50).
Deductible: The minimum amount the patient must pay before the insurance company will pay anything towards the charges/benefits will begin. This is paid out of pocket to the provider of the services, not to the insurance company. Often times insurance plans have separate In-Network and Out-of-Network deductibles.