Using Health Insurance to Cover Counseling for Individuals or Couples? You Might Think Twice.
Are you thinking of using health insurance to cover counseling?
With the current state of healthcare, you are indeed fortunate to have coverage. Many people feel that therapy is an expense that they cannot manage without it. If you are looking for information on using health insurance to cover counseling you can find a comprehensive overview of what it means for couples and individuals here. While it’s great to be covered, we don’t accept health insurance. Why wouldn’t we accept health insurance for individual or couples counseling?
I encourage you to investigate all options and arrive at an informed decision regarding your health care BEFORE using your benefits. That may mean using your insurance, and it may mean making another choice. You can always decide to use your benefits, but you cannot “undo” many of the negative consequences of using them. What are the risks of using your health insurance?
The required diagnosis of a mental illness
Insurance companies only pay for things that are “medically necessary.” This means that someone has to actually diagnose you with a mental health disorder AND prove that it is impacting your health on a day-to-day basis. Many of life’s problems are not mental health disorders. Many folks seek treatment before their issue would meet criteria for diagnosis as a mental health disorder, which is such a good thing.
Your insurance company will tell you, “A quote for benefits does not guarantee payment…” This means that you can be told over the phone that something is covered. You can be given an authorization number. And you can still be denied once they review the diagnosis. So if you think you are using health insurance to cover counseling, and the therapist receives a denial of the claim, you are still responsible for that.
What This Looks Like for Couples in Counseling Who Want to Use Insurance
If you are thinking of using health insurance to cover counseling for your marriage, be wary when an insurance company says that “cover couples counseling”. They are not referring to marital and relationship counseling. They mean that they cover a procedural code for a spouse to be present in therapy.
The procedure code tells insurance how the therapy happened; were you seen alone, with your spouse, or other family members? Most insurance will cover more than one person being in the room. So, they will tell you that they cover couples counseling because they will permit your spouse to be in the room with you while you receive counseling for your diagnosed mental health disorder. Your spouse is being considered a support to you in your treatment. This is typically Procedural Code 90847: “Family psychotherapy, conjoint psychotherapy with the patient present.”
This isn’t the only thing they look at.
Treatment not only includes the procedural code, but the diagnostic code. The diagnostic code tells the insurance company what mental illness the patient is being treated for. This is what they base medical necessity on. The diagnostic code for couples counseling is V-61.1, Counseling for Marital and Partner Problems.
This is the code that is typically rejected by insurance companies for not being medically necessary. It’s like trying to get your dental insurance to cover cosmetic whitening or veneers. Not going to happen. Insurance companies view relationship problems much in the same way that they view cosmetic procedures – they may be great, but they aren’t medically necessary. Using health insurance to cover counseling is not always straightforward. They want to see you using health insurance to cover counseling for things like depression, anxiety disorders, etc. Not relationship problems.
If you want to investigate using health insurance to cover counseling, ask your insurance if they cover the diagnostic code Z63.0- Problems in relationship with spouse or partner (sometimes also called v61.1). Do not just ask “do you cover couples/marriage counseling?” Be specific, because they will just tell you that they cover whatever you need unless you press them with actual code numbers. What they actually mean is they cover what they deem medically necessary.
So, How Does A Couples Therapist Accept Any Kind of Insurance?
In using health insurance to cover counseling for couples, the therapist will typically have to diagnose one of you with a mental health disorder, and then state that the other person is there in support of the partner. Present for all of their counseling. Counseling that is supposed to be addressing this disorder. That is not what marriage counseling is, and it is unethical to call it anything else just to make it medically necessary. One partner may have a diagnosed disorder, but that alone is not the focus of the treatment. The focus is on the relationship, and what is happening there. All other diagnoses are secondary.
You may be diagnosed with a “light” condition (that most people could fit the criteria for if they are in enough distress) such as Adjustment Disorder. But nonetheless, do you want a mental health diagnosis in your file if you don’t need it?
There is also the real risk that labeling one person as the “patient” will unbalance the treatment and pathologize the partner. Couples issues are best seen as something that the pair of you are addressing together, and even subtle notions that someone’s diagnosis can be blamed for all of the issues can create difficulties in therapy.
Even if one person does have a diagnosis, or several, this is not the primary focus of couples work and it is unethical to label it as such. We don’t contort our ethics for coverage.
In truth, most of our couples come to us because they recognize that putting any kind of insurance in charge of the route to saving their marriage can be shortsighted. The investment in a good couples counselor is something that is highly personal. Most of our clients want the best, and are willing to invest in their marriage just as they would invest in their futures in other ways. If this is not possible for you, scroll to the bottom to see other options to avoid using health insurance to cover counseling.
Understanding What a Diagnosis Means
If you get diagnosed with something, you should be able to decide who gets access to that info and why. You lose control of that information when it is in your file being faxed to anyone in the health care industry who ever requires access to it. A diagnosis says nothing about how you cope, what your strengths are, and which of the many symptoms you actually have. But a diagnosis will speak for you and may negatively impact your eligibility for things.
Children have a more difficult time in many ways when they are given a diagnosis. This diagnosis can follow them around in school, on to college, and be a barrier to doing certain things such as working with the Air Force or military, landing federal jobs, security clearances, aviation, and any other jobs requiring health-care related checks (many schools and healthcare institutions are now instigating these policies to screen out employees who may be unstable or cost too much money in mental health care and lost work days). If you child’s condition warrants a diagnosis, you may want to have some say over how that diagnosis functions in their life.
Loss of Confidentiality = Loss of Control Over Who Gets Your Information and What They Use It For
Anything that is part of your file becomes a permanent part of your file. This means that when you apply for new health insurance, life insurance, and many types of job, they can require an authorization to release information to view your entire medical record. With health care reform, being denied coverage due to a preexisting condition is thankfully less of an issue, however, companies can charge much higher premiums because of having ever been treated for a mental health issue.
A diagnosis is not the only thing that becomes part of your file. Insurance companies require treatment plans, progress reports, and many other types of personal information to determine what, if anything, they will cover. These details about your treatment should be private, but instead they are open and available to anyone with access. This could include potential employers. The average insurance claim passes through 14 people while it is being processed.
Having coverage doesn’t mean you are covered.
And if you are, prepare to fight for it.
The insurance company has several processes to approve treatment. They often only approve a certain number of sessions, even if more are necessary. They will often deny your claim and it could take months to get reimbursement, if at all. This can interrupt treatment. It can also take the form of a claw back, where they tell you something is covered and then end of denying it anyway, leaving the therapist to come back to your for compensation because you are ultimately responsible for treatment fees.
It should be between you and your therapist to determine what comes next in your treatment and how much of it you need. But, imagine an insurance agent sitting next to you in your session, clipboard in hand, making decisions about whether you truly “need” this therapy or not.
The rule of thumb when using insurance (directly or by reimbursement) is to contact them before treatment begins and get approved. Ask what information you will need to present for reimbursement. If and when you are denied, be prepared to go through several levels of appeals process with your therapist to get your rightful coverage. This can take weeks to months.
It All Boils Down to Choice
Many insurance companies do not give you a choice of what therapist you can see. They have preferred providers and you must choose one of them. Even if you are happy with your provider, as I said, you don’t have a choice about what information is put into your file and shared with everyone. You don’t get to take that information out of your file once it is there. This can be devastating for some, and a minor irritation to others. You are the only person who can decide what is right for you.
You have a choice in who you see, whether you see them for a long or short amount of time, and whether you’d rather use your insurance. We just want you to have all of the info you need to make the right decisions for your health and your family.
What Else Can I Do?
See if your insurance will reimburse you for out of network providers
Though we do not take insurance, we are happy to provide you with statements/invoices that many insurance companies require. And if you are denied coverage, we can fill out the necessary forms that they require the provider to complete for the appeals process.
If you are contacting your provider to see about coverage for out of network providers, ask the following:
- How many sessions are covered?
- Do I have to meet my deductible first? Is there an out of pocket max?
- Do they require a treatment plan or detailed summary for reimbursement?
- Do they reimburse for V Code 61.1 (for couples counseling)?
- What are the qualifications required of the practitioner? What information do they need from the therapist?
Use Pre-Tax Dollars
Other work-arounds include using your Health Savings or Flexible Spending Accounts to pay for therapy using pre-tax dollars. We do take all types of HSA and FSA cards with major credit logos on them. If you do not have one of these accounts, you could speak with your tax preparer to see if you could deduct therapy expenses from your taxes as an out-of-pocket health expense. Please note that HSA accounts make it harder to get couples therapy covered, so check on that before you begin.
Seek Lower Cost Therapy
There are several wonderful clinics in the Denver Metro Area that provide low cost therapy with intern counseling students. Two great options are:
One Other Thing
Something that we haven’t focused on, which is very pertinent, is that we have our own reasons for not using health insurance to cover counseling here. Insurance companies pay very little, and are increasingly making it difficult to get paid. Many won’t even accept new providers.
With 85% of our practice consisting of couples who are not using health insurance to cover counseling for the above reasons, it wouldn’t make much sense for us to try to get on a panel that won’t pay for our services. We also provide 70-75 minute couples sessions, and insurance only pays for 45-60 minute sessions. The actual rate that they pay is terrible. Time spent trying to get paid would detract from our time spent on better things, like providing free consultations. We prefer to do what we are meant to do – provide excellent counseling, rather than handcuff ourselves to the structure of the health insurance industry.