Does My Health Insurance Cover Couples Counseling?
Whenever you are able to use your health insurance to pay for services, it means that you have been given a medical diagnosis and that a health care professional has provided “medically necessary” treatment. If you and your partner are seeking help for a troubled relationship (e.g., marriage, life partnership, engagement, dating), the diagnosis is “Z63.0 Relational Problems” (per the Diagnostic and Statistical Manual of Mental Disorders [DSM-5]). Typically, insurance companies will NOT cover treatment—whether individual or conjoint—that is provided for the sole purpose of relationship improvement (e.g., communication skills or conflict resolution) because such treatment is not considered “medically necessary.” It’s like trying to get your dental insurance to cover cosmetic whitening or veneers—it’s not going to happen. Insurance companies view the treatment of relationship problems much in the same way that they view cosmetic procedures—it may be greatly beneficial, but it isn’t necessary.
Is there a situation when conjoint counseling IS covered by insurance?
Sort of… First, at least one partner must be diagnosed with a mental health disorder (e.g., depression, anxiety, substance use, OCD, eating disorder, etc.) that is negatively affecting his/her functioning on a day-to-day basis. Second, the treatment needs to focus on the mental health disorder and not on the relationship. Third, when the other partner attends sessions, it is in order to help with the stated diagnosis. In our opinion, this does not constitute true couples counseling as it does not allow for the interventions that we typically use with couples.
A number of insurance plans have a completely separate “behavioral health” deductible. In other words, even if you attend counseling sessions with an in-network provider, you are not necessarily working toward meeting your medical deductible (which only includes visits to medical doctors). Check with your health insurance if this is the case with your plan.
HSA and FSA
We accept HSA and FSA cards with major credit card logos.
If Dr Maxwell is an in-network provider for your plan, please get the following information from your HSA or FSA prior to the first session: The maximum allowed fee for each of the following service codes: 90791 (diagnostic evaluation [your intake appointment]); 90834 (psychotherapy, 45 minutes); and 90837 (psychotherapy, 60 minutes).
If Dr Maxwell is either an in-network or an out-of-network provider for your plan, please get the following information from your HSA or FSA prior to the first session: How the claims should be submitted: Most HSAs and FSAs will ask YOU, not us, to submit by mail or email a superbill with information such as diagnosis and type of service. This is something we can provide you as you leave our office or email you the same day.
As an out-of-network provider, Dr Maxwell can provide you with a detailed receipt with all the information needed to submit the expense to your insurance company and receive reimbursement according to your insurance coverage. Submitting the claim is therefore your responsibility. Payment in full is required at the time of your visit with Dr Maxwell.
Ahead of your intake appointment, we suggest that you call your insurance company and ask questions such as the following:
-Is pre-certification or pre-authorization required to see an out-of-network provider? If so, obtain and write down the authorization number or code.
-How many sessions will the insurance company authorize with an out-of-network provider?
-What are the “reasonable and customary” amounts covered for the initial intake session (CPT code 90791) and for subsequent sessions (CPT codes 90834 for 45 minutes or 90837 for 60 minutes)?
-Do you have a deductible you need to meet before your insurance starts to reimburse this out-of-network expense?
-If so, how much of the deductible do you still have to meet for this calendar year? As mentioned above under “Deductibles,” a number of insurance plans have a completely separate “behavioral health” deductible. Ask if this is the case with your plan.
-Is there a maximum number of sessions per calendar year, and is there a lifetime maximum number of sessions?
-If so, how many of these sessions have already been used?
What Are the Drawbacks of Using Health Insurance?
Anything that is part of your treatment becomes a permanent part of your health care record. When you apply for new health insurance, life insurance, and many types of jobs, you may be asked to provide an authorization to release information to view your entire medical record. With health care reform, being denied coverage due to a preexisting condition is less of an issue; however, insurance companies can charge much higher premiums if you have been treated for a mental health disorder.
The mental health diagnosis is not the only thing that becomes part of your file. Insurance companies require treatment plans, progress reports, and all of your personal information to determine medical necessity and what, if anything, they will cover. These details about your treatment should be private, but instead they will be open and available to anyone with access. This could include potential employers. It is reported that the processing of an average insurance claim typically involves a total of 14 people.