Among the first things new clients ask when they call to set up an appointment are: 1) what are our fees, and 2) will insurance cover those fees? I address some of these questions on our Fees & Insurance page, but this blog post will take a deeper dive into the world of insurance plans, mental health care, and therapy.

Seeking Coverage for Therapy from Your Health Care Plan

Some therapists do contract with insurance boards to provide mental health care within your plan. If you are struggling to make ends meet, this could be a good option for you. Just be aware that these therapists (because they charge less) often have a long wait list, see more clients per day, and may not be able to give you the same time slot every week.

I have chosen not to contract with insurance for a variety of reasons. This includes the fact that many of my clients do not want to have a diagnosis on their records (this is especially true for active service members), or they’re coming to therapy for a situation that would not be covered by insurance, like marital infidelity.

If you have a PPO plan and a diagnosable mental health condition, you can ask your Integrity Counseling Group therapist for a superbill, which is just a fancy name for a insurance-approved receipt. If you submit this superbill to your insurance plan, they will count your therapy sessions as treatment with an out-of-network provider. You will have to pay your out-of-network deductible, at which point the insurance will take on a portion of your expenses.

Therapist vs. Psychiatrist: What’s the Difference and What’s Covered?

Many people confuse therapy and psychiatry, but they have two very different functions in mental health care and will be accessed differently through your health insurance plan.

Therapy usually consists of weekly sessions that are 45 to 50 minutes long. During this time, you will have the opportunity to talk with your therapist about your situation. Your therapist will listen empathetically and provide feedback and suggestions as is appropriate. Most therapists have a masters degree, although psychologists do hold doctorates.

Psychiatry is very different. Psychiatrists are, in fact, medical doctors who have been through an MD program as well as advanced training in the area of mental health. As such, psychiatrists are authorized to prescribe medications. Therapists cannot do this.

Your first psychiatry session will be about 30 to 60 minutes long, so your psychiatrist can gather your medical history and learn about your current condition. Subsequent appointments will usually last about 15 minutes and are simple checkups to make sure that your medications are still working and there are no other health issues going on.

If you have an HMO, you will probably need a referral from your primary care physician to see a psychiatrist. Psychiatrists are usually billed as specialists, so any specialist copay would apply.

If you have a PPO, you can go to a psychiatrist directly. Just be aware of whether your chosen psychiatrist is in- or out-of-network, as your copay can vary greatly. As medical doctors, psychiatrists tend to accept a lot of different types of insurance, although more and more are opting out of the insurance system altogether.

Using Your Health Insurance Plan for Psychiatric Medications

If a psychiatrist does prescribe you medications, the good news is that it will be treated just like medications for any other condition. Your copay will vary based on the medication. Brand name medications are a lot more expensive than generics.

You should familiarize yourself with any prescription deductible you have and ask for generics whenever possible. If you’re concerned about how much a medication might cost, ask your pharmacist to run the script before filling it and give you a quote.

Most insurance plans also let you order a 3-month supply of medication by mail, which is often cheaper than purchasing it at your local pharmacy on a monthly basis. 

If you do need to take an expensive brand name medication, check with the manufacturer or your local pharmacy to see if there are any applicable coupons or discount programs. If you have Medicare, you may also be able to request a tier exception if the medication is medically necessary. This exception often requires that you try a cheaper medication in the same family before making the request.

What If You Are Hospitalized for Inpatient Mental Health Care?

Inpatient mental health care can consist of either 1) treatment at a general hospital, or 2) treatment at a dedicated mental health facility.

Either way, inpatient mental health care is for people who are in a mental health crisis and need to be kept overnight. A mental health crisis can include suicidal ideation, psychosis, paranoia, etc.

Your health plan will typically cover inpatient mental health care in the same way it would cover a general hospitalization. The exact copay will vary by plan, and depending on your insurance, there may be a limit as to how many days are covered.

Note that the California Mental Health Parity Act and federal MHPAEA may give you additional rights if you are diagnosed with a covered condition. However, neither act applies to Medicare or self-insured plans. Medicare has a lifetime limit on mental health inpatient services.

Cory Anderson, LMFT, CSAT, is a therapist and the founder of Integrity Counseling Group in San Diego, California. He specializes in treating sex addiction, substance abuse, and trauma. When Cory isn’t seeing clients, he enjoys mountain biking, kayaking, and spending time with his family.