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  • USING HEALTH INSURANCE WITH US

    Nearly every insurance or health benefits plan is required to cover psychotherapy services, at a level similar to regular medical care.  The specific rules and types of coverage vary so much that we can't possibly explain it all here.

    Usually, insurance plans require a specific agreement (contract) with each therapist in order to provide the most coverage/least cost to the client-- or sometimes they will only pay for therapy with a contracted  provider.
     
    It is important that you know what your plan(s) cover and whether the plan will pay for the counselor you choose. We have a handout you can use to help you get the information you need from your insurance company(ies). (see bottom of page)
     

    Our commitment to you: We will make every effort to provide services which are covered by your insurance plan(s) and to alert you when this is not the case.  However, there are too many insurance and benefit plans in various combinations to be able to track the specific requirements of each situation.  So we expect each client to be in charge of his/her healthcare and health benefits.  You are ultimately responsible for ensuring that your services are covered by your plan for your therapist.  This means that we will possibly give a discount to your insurance company, and then your share of the cost is your normal amount based on this discounted fee. 


    We will bill any insurance plans that we have agreements with.  If your plan does not have an agreement with us, we will try to bill the plan for you as a courtesy.  If we are unsuccessful, we can provide you with the necessary billing information to submit your own claim.
     
    It is important to be aware that insurance plans often have specific rules you must follow in order to have the healthplan pay for your therapy.  If these rules are not followed, they may not pay.  It is part of your agreement with us that if your company denies payment, then you agree to be responsible for the fees in lieu of using insurance. (with some exceptions)

     
    USEFUL NOTES:

    • Healthplan acceptance varies by clinician.  Check with your insurance company to ensure that your counselor is covered by your plan(s).
    • The therapist is not on your plan?  You might still be able to get the services paid for:  Ask if you have an 'out of network benefit'.  Some plans will pay for counselors who are not contracted with them-- but you may have to pay a larger share of the cost.
    • You can also ask about a 'single case agreement' or an exception to their policy.  We see this work most often when there is a clear reason to make an exception-- as in when it creates an undue hardship to use an 'in-network' therapist.  Lastly, we have agency "group" contracts with a small number of insurance companies, so they may authorize 'in network' benefits or costs to you even if the therapist is not in-network.  This also happens sometimes when an employer-sponsored healthplan changes to a new insurance, and the clinician is not on the new plan.
    • Preauthorization required?  If your plan requires pre-authorization to receive counseling services, we may need to require that we have a copy of the authorization prior to scheduling an appointment. Please allow up to 2 weeks for us to receive the authorization once you have contacted your insurer.
    • Some healthplans use “carve out” services.  This is when the healthplan pays another healthplan to manage the mental health services.  This catches people by surprise sometimes.  Be sure to check.
    • Telehealth Coverage:  Telehealth may be covered, not covered, or requires you to use a special service, and will not pay for you to see your clinician here with telehealth.
    • You have more than one insurance plan?  We may be able to bill both plans.  It is important to ask both of your insurance companies if your counselor is on their plan, and what restrictions or rules apply.
    • Changes to your coverage?  It is essential that you notify us immediately, to prevent any problems in coverage/payment which could cause you to be responsible for the fees.

    Frequently used terms for insurance plans:

    • Deductible-- amount of money the patient must spend before the insurance will pay anything for services.
    • In-Network or "preferred provider" or similar terms:  Providers who are contracted and approved to be seen under an insurance plan.  Typically, the amount of the cost to the patient is lower than out of network, or non-preferred.
    • Out-of-network provider:  This is when your clinician does not contract with the health plan.  Your plan may or may not cover out-of-network care, or may cover it at a lower amount.  If your clinician isn’t in-network, ask about out-of-network benefits.
    • Single Case Agreement:  This is a one-time exception, in which your healthplan will pay at the regular ‘in-network’ rate for an out-of-network provider.  You would need to ask your healthplan for this.
    • Copay or copayment:  A set amount, usually, which is the patient's responsibility to pay for service at the time of the appointment.  Copays are usually the same for counseling as they are for other "specialists" in health plans.
    • Co-insurance:  This usually refers to a percentage of the amount of the bill that the patient is responsible for.
    • Opt-out of benefits:  You may choose to self-pay for services and not bill insurance at all.
    • Self-Insured healthplan:  This is a special type of plan, and is subject to different rules than the usual healthplans in Washington State.  If your employer uses this type of plan, be sure to check your benefits carefully before using them.
    • Covered and Non-Covered Services:  Some services we offer may be covered by your plan, and some may not be.  Couples’ and family therapy may be some that are not covered.  You would be responsible to pay for these services in that case.  See Medical Necessity.
    • Medical Necessity:  For the service to be covered, it must be for a diagnosed condition, and the service used must be to help that condition. For instance, even if couple’s or family therapy are covered by your plan, but it does not meet this rule, it is not covered by the plan and you are responsible to pay.
    • Coordination of Benefits (COB):  This is when there are more than one healthplan which can be used to pay for healthcare.  There are specific rules for how healthplans pay.  It is critical that you keep us up to date on all healthplans you have, even if you do not plan to use them.
    • Timely filing of claims:  Nearly all healthplans have rules that require that any claims for services are filed with them by a deadline.  Some plans have very short time frames in which to submit claims for services.  Make sure that we have all of your insurance information, or changes to your coverage,  as quickly as possible.  This helps to protect you from a surprise bill.

     

    If you have Medicare:

    • Only a few clinicians accept Medicare.   Confirm this with the clinician before your first appointment.
    • Are your Medicare benefits managed by an insurance plan?  This is a Medicare Advantage Plan. You need to make sure that your clinician is BOTH a Medicare provider and is covered by your Medicare Advantage plan.  If the clinician is not covered by both, then it may not be covered.  (We do not accept the AARP/UHC Medicare Advantage Plan)

    We are unable to accept any of these Medicaid/Apple Health/Provider One and Marketplace/Exchange Plans:

    • Coordinated Care
    • Community Health Plans of Washington
    • Molina
    • United Healthcare of Washington Community Plan*
    • Wellpoint Washington (formerly Amerigroup)
      Regular Medicaid/Provider One

    *We can accept the United Healthcare commercial plans.