Saving money on therapy with out-of-network insurance benefits
Our mission at reflect is to make mental health more accessible. We know cost can be an issue -- which is why we negotiate with top therapists to reduce their rates by up to 50%.
We can also coordinate out-of-network reimbursement to help save you even more. Insurance reimbursement can be confusing, which is why many don’t even know about this potentially money-saving option. Let us explain:
What are in-network vs. out-of-network benefits?
Insurance companies pre-negotiate coverage with certain providers who are in-network. In these cases, your plan will pay the provider directly based on a fixed arrangement. You usually also have to pay a co-pay (fixed $) or coinsurance (% of costs) directly to the provider at the time of service.
Any other provider is considered out-of-network (OON). Your plan hasn’t negotiated with these providers, so they can charge their own rates. Depending on your plan, you may be able to apply out-of-network benefits to cover provider self-pay or cash-pay rates -- more on that in a minute.
For both in-network and out-of-network reimbursement, you often need to meet a minimum amount before your plan kicks in. That’s called a deductible. The required amounts often differ for in-network vs. out-of-network providers.
While this all may sound a bit confusing, don’t be discouraged. Our team can help work with you and your insurance plans to find you potential savings if you have out-of-network benefits.
How do out-of-network benefits work?
Many PPO plans reimburse for services with out-of-network providers. Unlike in-network benefits, you pay the full costs upfront and submit information to your plan for reimbursement. The percent you’re required to pay is called your coinsurance, and a deductible usually still applies.
Out-of-network coinsurance rates are commonly between 20 - 40%, meaning you will be reimbursed between 60 - 80% of the cost of each session, again after your deductible is met. This varies by plan.
Since reflect’s pre-negotiated rates are lower than market rates by up to 50%, the amount you pay with reflect may end up being close to an in-network provider, after out-of-network reimbursement.
An example of how you can save
Let’s say you have a 40% coinsurance rate for out-of-network (OON) benefits, with a $1,000 OON deductible per year.
For a $125 session with reflect, you’d pay 100% ($125) before your deductible is met. After you meet your deductible, you’d still pay $125 upfront and submit a claim to get $75 (60%) reimbursed by your plan. Your session would cost only $50.
Note, your OON deductible may apply to all OON coverage, not just what you spend with reflect. So if you hit your OON deductible with other covered costs earlier in the year, all of your reflect sessions will be covered under your OON benefits for the rest of that year!
Keep in mind, reimbursements are subject to individual plan terms and insurance company discretion. Don’t worry -- we can help you navigate these nuances.
What you need to do
Since individual plans may vary quite a bit, you'll need to do a bit of research to understand your specific plan benefits. Once you do, we can help with the annoying coordination to help you get reimbursed.
If you're considering therapy:
Confirm with your insurance plan whether out-of-network (OON) behavioral or mental health is covered and what your deductibles and coinsurance or co-pay rates are. PPO plans often offer out-of-network benefits.
Research what is required to file an out-of-network (OON) claim by logging into your health insurance provider’s portal or visiting their website. Here’s an example of a summary of benefits.
If this seems like a lot, not to worry. reflect will work with your therapist to provide you a superbill with all of this information.
Once you get matched and choose your therapist:
Let us know that you’d like to use your OON insurance benefits
Someone on our team will reach out to coordinate and get you set up
At the end of every month, we'll provide you with a superbill with detailed information on every session that you will use to file your OON claim
You’ll need to submit a claim directly with your insurance company. Here’s an example of a claim form that you would need to fill out. Many health insurance companies allow you to file claims completely online!
You get a reimbursement check directly from your health insurance company
If there are any issues, reflect is here to help navigate with you. Note, reimbursement is still up to your insurance company and based on your specific plan.
Note you can also use your HSA/FSA to pay for reflect sessions. This enables you to use pre-tax dollars to pay for your therapy sessions. If you have a special employer program that covers mental health benefits, we can also accommodate that as well. We’ll cover these in separate posts.
Email us here with any questions. We know this process can be confusing and stressful, so we are happy to answer any questions!
New to insurance lingo? Here are some helpful definitions:
Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $1,000 deductible, for example, you pay the first $1,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest. For therapy provided by providers in reflect’s network, you will need to look up your insurance plan’s “out-of-network” deductible.
Coinsurance: The percentage of costs of a covered health care service that you are responsible for after you've paid your deductible. Coinsurance rates are service specific, meaning that there is a specific rate for behavioral or mental health visits.
Allowed amount: The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.” Your insurance company will only reimburse you based on the allowed amount.
Let’s say your insurance allowed amount for therapy sessions is $100 per session and revisit the example above. Assuming that you have met your deductible and have a 40% coinsurance rate, you would pay $125 out of pocket for the therapy session, and be reimbursed $60.
Here’s how the math works:
Allowed amount x (1 - coinsurance rate) = $100 x (1 - 40%). = $60
Your plan will reimburse you a maximum of $60. That means you ultimately pay $65 for that session ($125 - 60), which is slightly more than the original example due to the cap.