Understanding Insurance Benefits

What Insurance Terms are Important to Know?

In-Network vs. Out-of-Network

In-network providers have a contract with your insurance company to provide therapy and testing services at negotiated rates. Out-of-network providers don’t have that contract, which usually means higher out-of-pocket costs for you.

Groundwork Psychology is in-network with Aetna and Blue Cross Blue Shield PPO plans (this includes Anthem and some other BCBS-affiliated plans). In-network plans provide direct reimbursement to Groundwork, and you only pay a portion of the fee as dictated by your plan details.

If you have a different insurance, we can still work with you as an out-of-network provider and provide documentation (called a superbill) that you can submit to your insurance for possible reimbursement. You will need to check with your plan to see what reimbursement they may offer. The difference here is that the reimbursement goes to you directly, because you will pay for any therapy or testing fees up-front.

Covered Services

Covered services are the specific types of healthcare that your insurance plan will help you pay for. While you will typically still be required to pay a portion of the cost, you will receive the service at a lower rate if your plan is in-network.  

Which Mental Health Services Does Insurance Cover?

For mental health services, most plans cover therapy sessions and psychological testing, but the extent varies. Some plans may cover weekly therapy indefinitely, while others limit you to a certain number of sessions per year. General diagnostic services are typically covered, though they may require prior authorization. However, academic-related testing is not a covered service and therefore clients are responsible for paying this portion of an evaluation. 

If you’re unsure whether a specific service is covered by your plan, contact your insurance company directly or ask us-we can help verify your benefits before you begin services.

Deductible

Your deductible is the amount you pay out-of-pocket before your insurance starts paying for services. Think of it as a threshold you need to meet each year in order to receive certain insurance benefits. For example, if your deductible is $1,500, you’ll pay the full cost of any health care services until you’ve spent $1,500 total. Deductibles reset every calendar year, so you start fresh each January.

Most health insurance plans include a deductible. A key difference between plans is whether your deductible applies to all health care services (including therapy and testing) or if your plan has service-specific deductibles, meaning it includes benefits for therapy where the deductible does not apply.

If your plan’s deductible applies to all health care services, then you will be responsible for paying the cost of therapy or testing services until you have met your deductible. This initial cost you pay for therapy or testing will apply to your deductible, which will benefit any other health care claims you make throughout the year. After you have met your deductible, your insurance kicks in and starts sharing the cost with you. Typically, your share is referred to as co-pay or co-insurance.

If your plan’s deductible does not apply to mental healthcare, then you may begin to share the costs with your insurance right away, again through a co-pay or co-insurance rate.

Copay

A copay is a fixed amount you pay each time you have an appointment. For instance, your plan might require a $30 copay per therapy session or a $50 copay for evaluations. You pay this amount at each visit, and your insurance pays for the rest.

If your deductible applies to mental healthcare services, the copay is what each visit would cost after your deductible has been met.

Coinsurance

Coinsurance is the percentage of the session cost you’re responsible for, usually after you’ve met your deductible. It’s a split between you and your insurance company.

If your coinsurance is 20%, that means your insurance pays 80% of the session fee and you pay 20%. So if a session costs $200, you’d pay $40 and insurance would cover $160.

Remember that most of the time, you will be responsible for the full cost of services until your deductible is met.

Out-of-Pocket Maximum

The “out-of-pocket maximum” is the most you’ll pay for all your covered health services in a plan year. Once you hit this limit, your insurance covers 100% of covered health services for the rest of the year.

For example, if your out-of-pocket max is $5,000 and you reach that amount through deductibles, copays, and coinsurance, you won’t pay anything more for the rest of the year when you receive covered services from in-network providers.

Using Insurance for Testing or Therapy at Groundwork

We know insurance is confusing, and we’re here to help you make sense of it. Before we start working together, we’ll verify your benefits and let you know what your insurance covers and if we are able to do so, we will share what your estimated out-of-pocket costs will be.

Understanding these terms helps you plan financially and avoid surprises. If you have questions about your specific plan or what you’ll owe, just ask. We’d rather you understand your costs upfront than be caught off guard later.