What Insurance Covers Couples Therapy?
Navigate insurance coverage for couples therapy. Get clear insights into plan benefits and discover practical payment solutions.
Couples therapy helps partners address challenges, improve communication, and strengthen their relationship. Understanding how health insurance covers couples therapy can be complex, often presenting challenges in determining specific benefits and requirements.
Understanding Coverage for Couples Therapy
Insurance companies cover mental health services deemed “medically necessary.” For couples therapy to be covered, it must address a diagnosable mental health condition in at least one partner. The therapy is considered an effective treatment for that diagnosed condition, not solely for relationship enhancement or general communication improvement.
Insurance providers distinguish between individual and couples therapy, even when using similar CPT codes like 90847 or 90846. The primary diagnosis is tied to an identified patient, meaning one individual must have a mental health diagnosis the therapy directly addresses. Relational distress alone, such as communication breakdowns or conflict, is not considered a billable diagnosis for insurance purposes.
Common exclusions or limitations apply to relationship counseling when there is no clinical diagnosis. While federal laws like the Mental Health Parity and Addiction Equity Act mandate equal coverage for mental health and physical health services, these protections do not extend to couples counseling unless tied to treating a diagnosable condition in an individual.
Determining Your Plan’s Specific Coverage
To determine your plan’s coverage for couples therapy, start by locating the member services phone number on your insurance card or by navigating your online member portal. Have your insurance card, member ID, and the policyholder’s full name and date of birth ready.
When contacting your insurance provider, ask specific questions about your mental health benefits. Inquire if your plan covers couples therapy using CPT codes 90847 and 90846. Ask if a mental health diagnosis is required for coverage and if there are specific in-network providers. Understand your financial responsibilities by asking about your deductible, copay, and coinsurance for mental health services.
Confirm if pre-authorization is required for couples therapy sessions. Ask about any annual limits on the number of sessions covered, as plans vary. Document the representative’s name, the date of your call, and any reference numbers provided.
Navigating the Process of Using Insurance
After confirming coverage, find a therapist who accepts your plan. Use online directories like Psychology Today, or contact your insurance company for a list of in-network providers. Some therapists may offer referrals or verify your benefits before starting sessions.
Once you select a therapist, their office will require your insurance information for billing. This includes your member ID, group number, and policyholder details. The therapist’s office will then submit claims to your insurance company.
After claims are processed, your insurance company will send you an Explanation of Benefits (EOB). This EOB details the services billed, the amount charged, what your insurance covered, and any remaining balance you owe. Review your EOB to understand how your benefits were applied and to verify charge accuracy.
Options When Insurance Doesn’t Cover It Fully
When insurance coverage for couples therapy is limited or unavailable, several alternative financial options can make therapy more accessible. Many therapists offer self-pay rates, allowing clients to pay directly for services without involving insurance. Some providers also offer sliding scale fees, adjusting rates based on a client’s income and financial situation.
If your insurance plan offers out-of-network benefits, you may receive partial reimbursement. You pay the therapist’s full fee upfront, then request a “superbill” to submit a claim directly to your insurance company. Some plans, like PPO or POS, offer out-of-network benefits, potentially reimbursing a percentage of the cost after your out-of-network deductible is met.
Employee Assistance Programs (EAPs) are a resource. These voluntary, work-based programs offered by many employers provide free and confidential assessments, short-term counseling, and referrals for various personal and work-related issues. EAPs cover a limited number of sessions, usually at no cost to the employee.