What Do I Ask My insurance Company So I know How Much The Sessions will cost Me?

When you call your insurance company, ask them how much their allowable amount (some insurance companies call this their Usual & Customary Rate) is for CPT code 90834 (Individual Therapy), 90847 (Couples Therapy) or 90853 (Group Therapy), depending on which service you’re considering engaging in, for a PhD therapist in zipcode 94104.

If you’re calling about a different therapist with a different degree, (MFT, MD) and/or a different zipcode, make sure you ask about those specific degrees/zipcodes, because they will typically reimburse for a PhD at a different rate than an MFT and an MD, etc., as well as they often reimburse at a different rate based on the zipcode of the therapist (they might pay more for an SF zipcode than a rural zipcode for example).

They will then tell you what their allowable amount is for that particular service for that therapist/location. Next ask them what % of the allowable amount they reimburse. And finally ask them what your out-of-network deductible is and how much you have left before you reach it. Now you have four pieces of information:

1) Allowable Amount for the service (Individual, Couples or Group Therapy)

2) % of Allowable Amount they will reimburse for that service

3) Your out-of network deductible

4) How much you have left before you reach your deductible

How Does the Math Work?

If your insurance company’s allowable amount for Group Therapy (CPT code 90853) for me is $100, and they will reimburse 80% of that amount, that means they will pay you $80 (80% of $100 = $80) of my total fee for group therapy, and you would be responsible for $40/session (My group fee $125 - $80 = $40).

Do They Start Reimbursing for My First Therapy Session?

Not necessarily but possibly. They begin reimbursing for their portion of the fee once you’ve met your out-of-network deductible. If you have had other out-of-network medical expenses that have contributed to your deductible, then they will start reimbursing sooner than if you haven’t had any other out-of-network expenses. Which is why you want to ask them much much you have left before you reach your deductible.

If you’re starting from scratch and have paid nothing towards your deductible, and your out-of-network deductible is $1500 for example, that means you’ll have to pay $1500 of what they consider the allowable amount before they start paying it.

So, in this example, if their allowable amount is $100/session, that means they will start reimbursing you $80/session once you’ve had 15 sessions ($1500/$100 = 15) and paid $1500 out of pocket of the amount they consider “allowed” ($100/session). They will not start reimbursing once you’ve spent $1500 on group (12 sessions), since they don’t consider my full group fee ($125) allowed. They only count their allowed amount towards the deductible.