How to Use Out-of-Network Insurance Benefits for Therapy in Massachusetts

What Are Out-of-Network Therapy Benefits?

Some insurance plans offer out-of-network benefits, which means they are willing to reimburse you for a portion of the costs you spend on your healthcare, even if it is with a provider outside of their network. 

These benefits are more common with PPO plans and less common with HMO plans, so if you need a reminder on the difference, click here!

How much does my healthcare really cost? 

Before we talk about how to get your insurance to reimburse you for what you spend on therapy, let’s talk about the different expenses involved with health insurance.

Premium: a fixed amount of money you pay to your plan every single month, no matter how frequently or infrequently you see a healthcare provider. 

Deductible: the amount of money you have to pay out-of-pocket for services, before full coverage kicks in.  Before you meet your deductible, you are paying a greater portion of the total cost of the visit, after you meet your deductible, you are paying a significantly lower amount. 

Co-insurance: refers to the practice of splitting the cost of a visit between you and your insurance company.  Before you meet your deductible, you are paying a greater percentage and your insurance is paying a smaller amount, after you meet your deductible, you are paying a smaller amount and your insurance is paying a larger amount. 

Co-pays: A fixed amount that you pay for an office visit no matter what.  If you’ve already met your deductible, this might be the only thing you pay. 

Out-of-pocket-maximum: the maximum amount you might have to pay out of pocket each year.  Once you pay this amount, the insurance covers 100% of the charges they have agreed to cover. 

How Much Does Therapy Cost? 

This depends a lot on your insurance, and also on your therapist, but let’s look at a few examples. 

Example 1: Astrid has commercial insurance with a $500/month premium, a $2,000 deductible, a $40 office visit co-pay and a $60 specialist visit co-pay and a $10,000 out-of-pocket maximum.  Her therapist is in-network with her insurance plan, and her insurance company and the therapist have negotiated a rate of $134/visit.  This means, even if the therapist would prefer to charge more money than this, this is the maximum they are allowed to charge.  Until Astrid meets her $2,000 a year deductible, her therapy sessions will cost $134/visit.  After she meets her deductible, she is responsible for paying the specialist co-pay of $60/visit.  This is because her insurance plan has decided that all telehealth visits are automatically specialist visits, and Astrid sees her therapist virtually. 

Example 2: Marcus has Masshealth for insurance, which is the Massachusetts version of Medicaid.  He is eligible for this insurance because of his limited income, and he does not pay a premium, deductible, or co-pay.  If he were to see a therapist who is in-network with his insurance, it would cost him $0/session.  Marcus has been having a hard time finding a therapist who accepts his insurance, so instead he sees a therapist through Open Path Collective, where the therapists have agreed to offer a sliding scale of $40-70/visit. 

Example 3: Janice has commercial health insurance similar to the plan Astrid has, but she cannot find a therapist who accepts her insurance plan, who has current openings, and the expertise in her particular mental health concern.  Janice chooses to see a therapist who does not accept insurance, who has extra knowledge and training in her project.  She pays $200.00/visit.

Example 4: Genevieve has Medicare (insurance that people who are 65+ or eligible for certain kinds of disability are eligible for).  Genevieve pays $185/month for Medicare.  Therapy is considered a Part B benefit, meaning Medicare covers 80% of the cost, and she is responsible for 20%.  Genevieve also has a Medicare supplement, which costs $200/month.  Supplemental insurance covers the 20% co-insurance for Part B benefits that Geneiveve would normally be responsible for.  So if Genevieve can find a therapist who accepts Medicare, she will not have to pay anything additional out of pocket.   

Do Most People Pay for Therapy Out of Pocket? 

In some of the examples we talked about, people chose to see a therapist who was out-of-network with their insurance.  This is actually pretty common, the National Alliance for Mental Illness reports one in four people receiving mental health therapy use an out-of-network provider. Some of this is driven by necessity, with folks having a hard time finding an in-network therapist who has current openings, but there are also several benefits to seeing an out-of-network provider like:

More specialization: Therapists with advanced training or niche expertise—such as sex therapy or pelvic pain—are more likely to operate outside of insurance networks. 

Shorter wait times: Out-of-network therapists often have more immediate availability, meaning you may be able to start sooner instead of waiting weeks or even months for an opening with an in-network provider.

More flexibility: Insurance plans sometimes place limitations on the number of therapy sessions you can have, the types of therapy they’ll cover, or even which diagnoses are eligible for reimbursement. Working with an out-of-network therapist gives you and your provider more freedom to decide what kind of care is best for you—without needing to fit your experience into a diagnostic box.

More privacy: When you use insurance, your therapy records can be audited by your insurance company.  This means they can read the highly personal notes your therapist keeps about the details of what you discuss in therapy. Choosing to work with an out-of-network therapist can offer an extra layer of privacy protection.  For our sex therapy patients, especially those that want to discuss kinks, fetishes, non-monogamy, or sex work, there’s peace of mind knowing that no one will be looking over their shoulder. 

How to Check if You Have Out-of-Network Coverage for Therapy

You need to call your insurance plan and ask questions like: 

1. Do I have out-of-network benefits for mental health treatment?
2. Can I access these benefits before or after I meet my deductible?
3. Is the reimbursement a fixed rate or a portion of the therapist’s fees?
4. Do my benefits cover certain CPT codes and not others? (A CPT code is the language providers use to communicate to the insurance company about the duration of the visit.  Some insurance plans will only cover sessions of a certain length).
5. Do my benefits cover certain providers and not others? (For example, clinical social workers, clinical psychologists, marriage and family therapists and mental health counselors are all different flavors of “therapist” some plans might cover certain providers and not others).
6. How do I submit a superbill?
7. How long will it take the claim to be processed? 

If I’m seeing a therapist who is out-of-network, how do I get reimbursed?

If you have determined that your therapist is out-of-network, and your insurance offers out-of-network benefits, you can ask your therapist for a “superbill”. 

A superbill is a specialized type of receipt that will include: 

• Your name, address, date of birth and phone number
• Your therapists name, national provider identification number, tax ID and license number
• The CPT code that describes the type and length of visit you were seen for
• The mental health diagnosis you were treated for
• Confirmation that you have already paid your therapist for the visit 

Your therapist can generate a superbill for every visit, or for several visits on a monthly basis, and then you submit them to your insurance company. The reimbursement process should take about a month, but it might take up to three months. 

Since most therapists use an electronic medical record (though not required it is highly incentivized by things like the HITECH Act) they can generate a superbill with the click of a button.  There are also companies like reimbursify that can help you submit and track out-of-network claims. 

How Much Will I Get Reimbursed for Therapy?

The Pomegranate Institute sees a range of different responses from insurance companies when it comes to out-of-network benefits in Massachusetts.  Here are some examples: 

Jessamin’s insurance told her that they are willing to reimburse her for 60% of the cost of her therapy sessions once she meets the deductible associated with her plan.  Her therapist charges $175.00, which is the average national cost for out-of-pocket therapy.  Since her deductible is $2,000, if she accesses no other healthcare, she will pay her therapist’s full fee without any reimbursement for twelve visits.  Afterwards, her insurance will reimburse her for $105 a session.

Cole and Alec are seeking relationship therapy.  They have out-of-network benefits through their insurance plan, and their insurance reimburses them for a fixed amount of $100.00 a session.  Their insurance only reimburses for a 60-minute session, not a 90-minute session.

Jasper has out-of-network benefits for mental health, and his insurance plan reimburses for twelve sessions of therapy a year at the therapist’s full fee, once he has met his deductible.



Can I Use My Flex Spending Account or My Health Savings Account to Pay for Therapy? 

 FSAs and HSAs give you the opportunity to set aside money pre-tax to pay for healthcare costs.  They are different accounts, though some people have both.  If you need a refresher on the difference, fidelity has a great primer. 

In general, you can use your HSA or FSA to pay for therapy, so long as the therapy is provided by a qualified and licensed provider, and is for the treatment of a diagnosed medical condition. 

Is The Pomegranate Institute an out-of-network provider? 

Yes, The Pomegranate Institute doesn’t take insurance.  If you want more information about why therapists choose not to accept insurance, check out our article Why So Many Therapist’s Don’t Take Insurance Anymore – Especially in Massachusetts.  

We are happy to help patients submit claims for insurance reimbursement. We do it all the time, and our patients have had reasonably good experiences getting reimbursed. 

I think I want to try getting reimbursed for therapy, what should I do next? 

If you’re looking for a Massachusetts sex therapist who knows about insurance reimbursement, the Pomegranate Institute would love to meet you! You can schedule a 30-minute consult to see if we’re a good fit by clicking this link, it will take you right to our calendar!