Once a person has decided to seek out a provider, they should check what type of coverage their insurance offers. Broadly speaking, most insurance companies will have different coverage for providers that are in their network versus providers that are outside of their network. There are two main factors that tend to differ for in-network and out-of-network coverage that affect the end cost for patients: the per-session rate and the percentage of that rate that is covered by their insurance. For in-network providers, the insurance provider will have already negotiated a pre-set rate that the provider must accept to be in their network. Out-of-network providers on the other hand set their own rates. The percentage of the rate covered by an insurance carrier for in-network providers tends to also be higher than the percentage covered for out-of-network providers. So let’s look at how this might play out. For an insurance policy that sets their pre-negotiated per-session rate with a provider at $100 and agrees to pay 80% of in-network costs, the patient would end up owing $20 per session. That same insurance policy may agree to pay 60% of out-of-network costs. If the out-of-network provider a patient sees sets their rate at $150 per session then their insurance would pay $90 (i.e. 150 x .6) and the patient would owe the remaining $60 per session.
Given the financial differences in seeing an in-network versus out-of-network provider, it is understandable that many people seek to look in-network first. However, going out-of-network often provides a patient with greater flexibility to seek out a provider who they feel like is a good fit, or to whom they have been specifically referred. It is worth noting that in some areas such as New York City and Washington, D.C. it is common practice for many therapists to choose to work solely as out-of-network providers, so the advantage in flexibility of going out-of-network is often more pronounced in those locations. If a person does decide to look out-of-network, here are some good questions for them to check about their insurance policy:
Do I have out-of-network benefits?
What is my out-of-network deductible and has it been met?
Once I meet my out-of-network deductible, what percentage of services will be reimbursed?
Is there a limit (sometimes referred to as a usual-and-customary rate or an allowed amount) to how much my insurance will pay for each session?
Is there are limit to the number of sessions covered per calendar year?