Tips for Using Your Insurance in Therapy

by Marijane DiCandia


tips for using your insurance in therapyJanuary is right around the corner and you may want to make some changes in your insurance plan to give you the flexibility to choose a therapist who you feel is your best fit.  Choosing the best therapist for your individual needs and with whom you feel an easy rapport from the get go can make a very big difference in how successful your therapeutic gains are.  Trusting your therapist is the door to how safe you feel to be yourself, show your issues and feel your deepest feelings.  Connection to your therapist is the gateway to creating deeper connections and closer relationships with the people in your life.


Here are some tips for using your insurance in therapy. It’s a simple guide to how different insurances cover different ways that licensed therapists or centers, like Sync in Pasadena and Sierra Madre bill your insurance.


There are two ways that psychotherapists, psychologists and other mental health professionals accept insurance…in-network and out-of-network.  In the Los Angeles area, including Sierra Madre and Pasadena it is estimated that only 25 % of caretakers are in-network with any insurance companies.  This can be very frustrating for a plan holder who pays quite a bit for coverage who, when looking for a qualified professional to see for services, finds out from calling the list provided by their plan, are not taking new patients.  Due to the low percentage of providers who are under the umbrella of your insurance plan, they are often deluged with calls and simply booked to the max.


Why Your Therapist Is Out-of-Network

You must be wondering why more mental health professionals are not under that umbrella? Often, the insurance companies do not pay the fee that the provider needs in order to sustain a private practice.  In order to cover expenses, providers who work “in network” must take more than the usual number of patients to make up for receiving a lower fee than is customary in California.  Also, working under the umbrella of an insurance company means a lot more paperwork and often mental health providers don’t have the time to do it. 


It’s a choice all providers must make based on their abilities, energy and susceptibility to “compassion fatigue”, a known condition facing all of us in the helping professions.  This is why fireman are only permitted to work 2 1/2 days in week.  We sure wouldn’t want an exhausted fireman facing yet another disaster when he or she has just come from one.  There are many excellent mental health providers who work “in-network”, if you are able to find one.  When you do find one you will pay a different co-pay as per their mental health regulations.  Usually, it will be about $60.  But will vary greatly from plan to plan.


Key Questions to Ask Your Insurance Provider

Here at Sync, most of our providers take “out of network” insurance.  Every plan out there has huge differences in how they reimburse you for this.  This is what you need to be informed about when choosing your plan this coming January, if you want the flexibility to choose either in or out-of-network.  Here is what you need to know in order of importance:


  1. Does your company pay anything for out of network mental health outpatient providers? Your plan will have to be either a PPO or an EPO.  If it’s HMO they simply don’t pay for out of network except for highly unusual reasons.
  2. If so, what is the deductible that you will need to meet before they start to pay? A word about deductibles…this is an extremely important question to find out as different plans within the same company vary greatly.  For instance, your PPO plan may have anywhere from a $250.00 deductible to a $7000.00 deductible.  This deductible will only count for one year and every January its starts anew.  So, let’s say you choose a high deductible of $5000. That would mean if the mental health professional you choose has a fee of $120.00 and you are seeing them weekly, it will take until the middle of November for your insurance to kick in.
  3. What percentage of the providers fee do they pay after the deductible is met?  A common percentage is 60&, a better plan will pay 70% or even 80% or best obviously 100%.  They can also pay less of a percentage.


So, how does one end up with the right plan with the most flexibility? First of all, just understanding how much plans vary is the first step.  Then, asking the right questions and getting the facts means talking to your insurance company or agent until they give you the facts.  Sometimes this can be a little daunting as it’s not often even that clear to the sales people or to the agents what the differences are as most people don’t ask. 


Using the Insurance Provided through Your Employer

Many people are offered plans through their jobs.  You may feel limited to what plans your company is offering.  However, if you are not happy with your “out of network” coverage, I have often met people who have gone to their HR department and asked if they can choose another plan if they pay the difference.  Many companies are willing to do this as they are offering certain plans to make things easy for their employees but have no problem with adding another plan as long as it’s with the companies they are offering. 


For instance, if they are offering Blue Shield Preferred PPO, the deductible last year was $5000.  If you up your plan to Blue Shield Platinum, the deductible is $300.  If this is your year for seeing a therapist and your feel a provider you have met is the best one for you and they only take out-of-network, your savings over the year will be significant even if you are paying $100 more a month for the upgraded plan.  Pus, you have the added advantage of seeing any medical professional who is not in-network with any company.  These professionals are usually specialists or alternative.


There is more information about this in regard to how the billing works and what is the best way for you to work with your out of network provider. You are welcome to call me if you have questions before it’s time to choose again.  Any of our Sync therapists, Pasadena, Sierra Madre or any of our locations will be happy to include insurance questions during your initial discussion regarding your potential treatment.  Being as unstressed about the financial end of therapy will make for a better experience and getting what you want from treatment.  We all pay for that insurance…might as well make it work for us and be exactly what we want.


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