Using Insurance for Individuals, Couples and Families

 How are behavioral health insurance claims processed?

IN-NETWORK INSURANCE:
When therapy is a treatment service and is deemed a 'medical necessity,' we submit insurance claims on our client's behalf and handle any insurance follow-up. Co-payments may apply after insurance coverage. Please check your benefits and policy. 

List of Insurances We Accept when Therapy is a Treatment Deemed a Medical Necessity 

OUT-OF-NETWORK INSURANCE AND PRIVATE PAY:
For our out-of-network clients, when therapy is a treatment service and is deemed a 'medical necessity,' after payment, we submit a superbill claim for reimbursement directly to the client's insurance company and handle any insurance follow-up. The client will receive full or partial reimbursement from their insurance company. Reimbursement is not 100% guaranteed and is based on the client's out-of-network insurance coverage. 

Does Behavioral Health Insurance cover couples and Family Therapy?

Health insurance providers limit coverage to services deemed as 'medical necessities,' which typically require a confirmed mental health diagnosis. This diagnosis becomes a permanent part of one's medical records. Before utilizing insurance, it is advisable to discuss this with your therapist during the initial session to evaluate symptoms and determine the need for a mental health diagnosis.

Professional counseling and therapy address various areas, such as self-improvement, career guidance, and parenting issues. However, these and other couples and marriage issues related to conflict, blended families, divorce, and pre-marital relationships are generally not classified as "medical necessities" by most insurance companies. To use medical insurance, a clinical diagnosis of a serious mental health issue (as defined in the DSM-5) from a primary care physician, psychiatrist, or licensed mental health professional is required. The clinical mental health diagnosis impedes an individual's functioning and is disruptive to the family system.

Can I use my behavioral health insurance under the 'anxiety, unspecified' diagnosis for couples therapy?

Despite some insurers initially indicating coverage for such services, clients often face disappointment when claims are rejected later on. It is recommended to request written confirmation from your insurance provider regarding coverage for marriage or relationship counseling to avoid misunderstandings that can lead to out-of-pocket expenses.

Insurance coverage usually extends to counseling focused on mental health disorders like depression, generalized anxiety, and PTSD through individual psychotherapy or sometimes family therapy. It is important to verify with the insurance company if family therapy is covered for unmarried couples since definitions of "family" can vary among insurers.

What about if my partner or I have been diagnosed with an unrelated issue and are seeking marriage counseling due to infidelity, lack of intimacy, empty nest syndrome, or constant arguments?

When seeking counseling for a mental health disorder considered a medical necessity, the therapist's primary focus is on treating the specific disorder rather than providing marriage counseling. While addressing individual mental health concerns may indirectly benefit relationships, the treatment itself does not constitute marriage counseling. During the initial session, licensed therapists and other mental health professionals recommend clients and patients see their primary care physician to rule out biological, neurological, or biosocial issues that contribute to addiction and other behavioral problems or new behaviors. 

In situations where individuals desire marriage counseling covered by insurance but it is not considered a medical necessity by providers, therapists face ethical dilemmas. Keep in mind that insurance companies review clinical records to ensure services align with their guidelines, and inappropriate charges may need to be reimbursed.

If you are experiencing challenges in your relationship that are escalating into tension and distance, seeking professional help is encouraged regardless of financial constraints. Marriage and family therapy can be a worthwhile investment that is worth temporarily reprioritizing finances. Some counselors offer fee adjustments for families facing financial difficulties, while community organizations may provide subsidized professional counseling services.

To determine whether you require family therapy or marriage/relationship counseling, consider the primary issue you wish to address in therapy: focusing on marital/relationship dynamics or supporting a partner dealing with a specific mental health issue.

Read more about medical billing for couples and families:

1. https://blog.zencare.co/pay-for-couples-counseling/ 
2. https://www.thebalancemoney.com/is-couples-therapy-covered-by-insurance-4782914 
3. https://www.goodrx.com/health-topic/mental-health/is-marriage-counseling-covered-by-insurance
4. https://www.talkspace.com/blog/does-insurance-cover-marriage-counseling/ 

We offer sliding scale fees where applicable.