Is Couple Therapy Covered by Insurance?
Understand insurance coverage for couple therapy. Learn to verify benefits, navigate complexities, and discover alternative payment solutions.
Couple therapy, a valuable resource for relationship challenges, often has complex insurance coverage. Unlike individual therapy, which receives clearer coverage, couple therapy presents unique considerations. This distinction arises because policies address diagnosed mental health conditions in individuals, not just relationship dynamics.
Insurance Coverage for Couple Therapy: The Basics
Insurance coverage for couple therapy often differs from individual therapy due to “medical necessity.” Insurers generally require a mental health diagnosis for one partner, the “identified patient,” for coverage. Therapy must address this diagnosed condition, and sessions must be an effective treatment. Relationship issues alone are typically not considered a mental health diagnosis.
Couple therapy is usually covered when one partner has a diagnosed condition, such as adjustment disorder, major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder, where relationship factors impact the mental illness. The therapist must document how the therapy directly relates to improving the diagnosed condition. Common Procedural Terminology (CPT) code 90847, “family psychotherapy, conjoint psychotherapy with the patient present,” is typically used for these sessions.
Verifying Your Specific Insurance Benefits
Determining your specific insurance coverage for couple therapy requires proactive steps before beginning treatment. You should have your policy number, group number, and subscriber ID readily available when contacting your insurer. The member services number, typically found on the back of your insurance card, is the direct line to inquire about your benefits.
When speaking with a representative, ask specific questions to understand your coverage fully. Inquire if your plan covers CPT code 90847 for couple or family therapy and if a mental health diagnosis is required for coverage. Also ask about your deductible, whether it has been met, and what your co-pay or co-insurance will be for outpatient mental health services. Additionally, ask if you have out-of-network benefits for mental health and, if so, the reimbursement rate and whether pre-authorization is required for services. A deductible is the amount paid before insurance shares costs; a co-pay is a fixed amount per service; and co-insurance is a percentage of costs after the deductible. Pre-authorization means the insurer approves treatment medical necessity before coverage.
Working with Therapists and Handling Billing
Once you have clarified your insurance benefits, understanding how therapists handle billing is the next step. If your therapist is in-network, they have a contract with your insurance company and will typically bill the insurer directly, with you responsible for co-pays or co-insurance. This often results in lower and more predictable out-of-pocket costs.
For out-of-network therapists, you typically pay directly for each session, then seek reimbursement from your insurer. The therapist provides a “superbill,” a detailed invoice for insurance claims, including diagnosis codes, CPT codes, and service dates/costs. You submit this superbill to your insurance company, often online or by mail, to request partial reimbursement based on your out-of-network benefits.
Exploring Alternative Payment Options
If traditional insurance coverage for couple therapy is unavailable or insufficient, alternative payment options can make therapy accessible. Many therapists offer a “sliding scale” fee structure, adjusting rates based on income. This can significantly reduce per-session cost, with some services ranging from $40-$80.
Employee Assistance Programs (EAPs), often provided by employers, offer limited free counseling sessions. These programs cover various issues, including relationship concerns, without requiring a mental health diagnosis. University training clinics, affiliated with psychology or counseling programs, provide lower-cost therapy. These services are delivered by graduate students under licensed supervision, potentially costing around $50.
Community mental health centers offer services at reduced rates or on a sliding scale, sometimes government-funded, aiming to provide affordable mental healthcare. Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) can also pay for therapy expenses. These tax-advantaged accounts allow pre-tax dollars for eligible medical and mental health expenses.