I’m going to a psychoanalyst who charges 250 out of network.
I’ve been under the impression that my health insurance can reimburse me for out-of-network/out-of-pocket expenses as long as they cover the procedure code.
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It depends on your plan. Some plans will have out of network benefits, but they will be based on the amount they would’ve paid an in network provider. Some plans will have those benefits, but only if you show good “need” for it (i.e. continuity of care from when you were on a past insurance). Some plans won’t cover out of network non-emergency care at all.
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Therapist here… a few things to consider:
- Check your plan documents to see if you have out-of-network (OON) coverage.
- If you do, are you submitting superbills to your insurance, or is your provider handling that for you?
- If you have OON coverage, you probably have a separate deductible from your in-network one.
- Your therapist can charge you their full fee upfront, and the insurance will reimburse you part of that. You typically won’t get the full amount back.
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Sure, if your policy states that it covers OON physicians. It would be a separate deductible as well, which is likely much higher than an in network deductible.
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As long as your insurance plan covers out-of-network (OON) benefits, you can use them. The problem is that insurance doesn’t pay based on what the provider charges. Instead, they use a standard rate, often based on Medicare. So if your psychoanalyst charges $X, your insurance might only credit a smaller amount, $Y, toward your OON deductible or out-of-pocket max.
Also, keep in mind balance billing. OON providers can charge you the difference between what insurance covers and their actual rate. For example, if insurance pays $100 and the psychoanalyst charges $250, you might be billed for the remaining $150.
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Yes my plan has a $0 out of network deductible and reimburses 80% of the cost of out of network care
But it’s a very unusual plan
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What’s your insurance? I need that plan lol
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Yes but only the allowed amount. If you have a service subject to your deductible, that is applied first in most cases.
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Many carriers cover out-of-network claims, but probably not in the way you’d expect. You likely won’t be happy with the premium if you’re hoping insurance will cover all the smaller expenses.
People often don’t realize that premiums must exceed total claims. Premiums are essentially the average monthly cost of claims plus an administrative fee.
I just completed a renewal and offered both a $0 deductible plan and existing high-deductible health plans (HDHPs). No one wanted to pay for the $0 deductible plan. Even though they dislike HDHPs, they still saw them as the best option. They could have chosen any carrier or plan but stuck with the HDHP.
That’s how healthcare works in the U.S.