Does Insurance Pay for Marriage Counseling?

Marriage counseling helps couples navigate challenges and strengthen their relationship. This article clarifies health insurance coverage for mental health services, including marriage counseling, and guides individuals on utilizing their benefits.

Understanding Insurance Coverage for Counseling

Health insurance plans cover mental health services. For insurance to cover counseling, a diagnosable mental health condition is typically required for at least one partner. Pure “marital problems” without an underlying individual diagnosis are usually not considered a billable medical necessity by insurers.

Federal legislation, such as the Mental Health Parity and Addiction Equity Act (MHPAEA), ensures mental health and substance use disorder benefits are comparable to medical and surgical benefits. This means financial requirements, like deductibles and co-payments, and treatment limitations, such as visit limits, should be no more restrictive for mental health care than for physical health care.

Coverage also depends on the professional qualifications of the counselor. Most insurance plans require the provider to be a licensed professional, such as a Licensed Marriage and Family Therapist (LMFT), a psychologist, a Licensed Professional Counselor (LPC), or a Licensed Clinical Social Worker (LCSW).

HMO plans typically require members to choose a primary care provider (PCP) and obtain referrals for specialists, often limiting choices to an in-network directory. PPO plans offer more flexibility, allowing individuals to see out-of-network providers, though usually at a higher cost share. Point of Service (POS) plans blend aspects of both, often requiring a PCP referral for in-network care while allowing out-of-network options with higher costs.

Checking Your Specific Insurance Policy

To determine coverage for marriage counseling, contact your insurance provider directly. Use the member services phone number on your insurance card or access your online member portal.

Inquire if your plan includes mental health benefits for outpatient therapy services. Specifically ask if CPT code 90847, representing family psychotherapy with the patient present, is a covered service if one partner has a billable diagnosis.

Clarify your financial responsibilities. Ask about your deductible, the amount you must pay out-of-pocket before insurance covers costs. Understand how much of your deductible has been met for the current plan year. Inquire about your co-pay or co-insurance amounts for mental health services, which are fixed amounts or percentages you pay for each session after your deductible is satisfied.

Determine if pre-authorization is required for counseling sessions. Ask if there are any limits on the number of therapy sessions covered per year. Confirm whether a referral from a primary care physician is necessary to access mental health services. Inquire about your out-of-network benefits for mental health care, including any separate deductibles or reimbursement rates.

Engaging with Counseling Services Using Insurance

After gathering policy information, find a counseling professional who aligns with your insurance benefits. Many insurance companies provide online directories of in-network mental health providers. You can also ask your insurance representative for a list of covered therapists or use online platforms to filter by insurance plan. Always confirm a therapist’s in-network status directly with their office before your first appointment.

Most therapists or their administrative staff can help you understand the claim submission process. They will typically require your insurance information to verify benefits and process claims on your behalf.

For insurance claims to be processed, a billable diagnosis for one of the partners is usually required. The therapist will assess and assign an appropriate diagnostic code that meets the insurer’s criteria for medical necessity. This diagnosis, along with the CPT code for the therapy session (such as 90847), is submitted to your insurance company for reimbursement.

If your preferred therapist is not in-network, you may have options for reimbursement through out-of-network benefits. This involves paying the therapist directly and submitting a “superbill” to your insurance company for potential reimbursement. A superbill is a detailed receipt provided by the therapist that contains all the necessary information for your insurer to process an out-of-network claim, including diagnosis codes, procedure codes, and the therapist’s credentials. Your insurance company will then process this claim based on your out-of-network benefits, often reimbursing a percentage of the cost after any separate out-of-network deductible is met.

Considering Alternatives When Insurance Doesn’t Cover Fully

When insurance coverage for marriage counseling is limited or unavailable, alternative options can help manage costs. Many therapists offer services on a sliding scale, adjusting fees based on a client’s income and ability to pay.

Community mental health centers often provide counseling services at significantly reduced rates compared to private practices. These centers are frequently funded by government grants or non-profit organizations, allowing them to offer affordable care.

University training programs, particularly those affiliated with psychology, social work, or marriage and family therapy departments, may offer low-cost counseling. These services are provided by graduate students under the direct supervision of licensed and experienced faculty members.

Employee Assistance Programs (EAPs) are another resource, often provided by employers as a benefit. EAPs typically offer a limited number of free counseling sessions, usually between three to six, for employees and their immediate family members.

Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) provide tax-advantaged ways to pay for qualified medical expenses, including therapy services. Contributions to these accounts are made with pre-tax dollars, reducing your taxable income. Funds can be used for out-of-pocket therapy costs, including deductibles, co-pays, and services not covered by insurance.