By: Felix A. Perez, LCSW, Director, Founder and Owner of Perez Therapy, LLC and a psychotherapist and social worker for 20 years.
Introduction
Navigating the health system can be daunting, and the behavioral health system is no easier to navigate, unfortunately. I’ve put together this guide, to help people navigate in-network and out-of-network systems. Whether you’re looking to receive therapy from Perez Therapy, or another provider in the Philadelphia area, this blog can help point you in the right direction.
This guide is written from my personal experience with insurance. I do not consider myself an expert in the insurance industry by any means. I recommend reading our other blog, “Finding the Right Therapist: Let’s Make a Match”. Here, we talk about how to find a therapist that is the right match for you.
1. First ask yourself: Why do I want therapy, and what do I want to get out of it?
Before you even consider whether you are using your insurance, you should first know what you want to achieve in therapy. Not all reasons are equal, and not all therapy treatments are covered by insurance companies.
Ask yourself these questions:
What is my motivation for looking for therapy?
Is this a “big problem” or a “little problem”?
Do I only want short-term therapy, or could I commit to longer-term therapy?
What would it take for me to start therapy and really stick to it?
In the end, what do I want to get out of it?
What are my expectations for therapy and for my therapist?
Am I prepared for bumps in the road ahead as I try to match with the right therapist?
Your goals and expectations for therapy should drive who you pick to be your therapist. Whether you have insurance or not, consider what you want to address and who is the best to help you address it.
2. Consider if you must use your insurance or not.
Ideally, therapy is free or low-cost, right? But unfortunately it isn’t always the case. Finding an in-network therapist may be tough, especially if you consider your priorities in a therapist, availability, etc.
Health Insurance networks give you access to a pool of professionals, but be sure that this pool has the person most suited to help you with your particular issue. It’s okay to “self assess” here. Do you just need someone to talk to? Are you more particular with who you want to talk to? That’s okay too.
Trusting the therapist and the process are essential ingredients for successful therapy.
Our company, Perez Therapy, is in-network with a few insurances (listed in detail below), and if you live in Pennsylvania, we may be able to help you.
2. Does your health plan cover outpatient mental health?
More important than if you believe you must use your health insurance, is if you actually have any coverage. Most plans do offer some outpatient mental health reimbursement, but some may require that you first use their Employee Assistance Program (EAP) to first be assigned to a therapist.
Just a warning, a person assigned to you as your EAP therapist might not actually be in-network with your health plan, so double check that and if you expect to continue with the EAP therapist post discharge.
3. How do I find a therapist in-network?
Your health insurance client portal and PsychologyToday.com are the best places to find a therapist online. Just be aware that the insurance filter on PsychologyToday.com may not accurately show which therapists take that insurance, so be sure to double-check their profiles and the clinician’s website.
Therapists will often put this Psychology Today symbol below on their websites. It helps potential clients know that the therapist's stated credentials and license have been verified.
Click HERE for our profile on Psychology Today.
Keep in mind, providers sometimes close themselves for people who are in-network and have out-of-network slots only. In these cases, you would be waiving your use of in-network and out of network (OON) benefits.
4. What is a behavioral health “carve-out”?
Your physical health insurance company may also be your behavioral health insurer. Sometimes, health insurances have what they call a "carve-out" for behavioral health services where they contract a third-party payer, like Magellan Behavioral Health, to provide behavioral health managed care. Such is the case for people who have Blue Cross/Blue Shield accounts in the region.
If you have Independence Blue Cross (IBX) or Capital Blue Cross, and are an employee of the University of Pennsylvania or Tower Health, you probably have Quest Behavioral Health, which is the carve-out for their employee's health plan. If you have another employer and have IBX, your carve-out is probably Magellan Behavioral Health. Perez Therapy, for example, is credentialed with Quest, but we are not yet credentialed with Magellan (we aim to be in-network 2024).
5. Understand your benefits and any limits on coverage.
We suggest reading some helpful tips on the Centers for Medicaid and Medicare Services (CMS). You can find some information on navigating your care with health insurers here: https://www.cms.gov/files/document/11819-sample-explanation-benefits-508.pdf
STEP 1: Check if your behavioral health benefits are managed by your primary health insurance company, like a Blue Cross/Blue Shield or if your plan has a carve-out for Quest, Magellan, or some other third party company.
STEP 2: Log into the client portal for the health insurance company that manages your behavioral health.
STEP 3: Get your Explanation of Benefits (EOB) or a Summary of Benefits, which should explain what your behavioral health benefits are.
STEP 4: We recommend that you call your health insurance company and clarify what your health benefits are.
6. Ask your health insurance these questions about your specific plan. Not all plans are the same! Even from the same insurance company.
Are outpatient mental health services covered in my plan in-network?
Do I have any mental health out-of-network benefits in my plan?
What is my deductible, and is there a separate deductible for mental health?
After I reach my deductible, what is covered?
What is my copay?
Are telehealth services approved services to bill for? Is there a copay required for those visits?
How do I find providers in-network?
How do I get reimbursed for any of the services that I pay for? Do I have to complete a special form, or are my therapist’s statements/invoices sufficient?
What types of licenses are required for reimbursement for therapy? Do non-licensed or LSWs count? (see #7 below)
7. Clarify which kind of therapists are eligible to be counted towards your out-of-network (OON) benefits.
Not every therapist will qualify to count towards your OON benefits. Some plans require that therapists be “fully clinically licensed”. Perez Therapy has Licensed Social Workers (LSWs) on staff, who are licensed and allowed in-network. They work under the supervision of an LCSW, who is fully clinically licensed.
Here are examples of clinical licenses for therapists.
LCSW: Licensed Clinical Social Worker
LPC: Licensed Professional Counselor
LMFT: Licensed Marriage and Family Therapist
Licensed Psychologist: Almost always someone with a PhD or PsyD
We should note that there are some psychiatrists who practice psychotherapy, but it is less common to find a psychiatrist who practices therapy, much less one that practices and accepts insurance reimbursement.
8. Does your insurance cover certain specialties?
When discussing specialties, it’s important to first consider your reason for coming to therapy. In some cases, you know you need specialized care, because of what you want to address in therapy. Other times, it’s best to get a professional assessment based on your reasons for wanting to explore psychotherapy. After a proper evaluation, you can get further information on what next steps should be.
At Perez Therapy, we provide outpatient mental health individual therapy, couples counseling, family therapy and group therapy. You may need other specialized treatment, like substance use counseling, rehab, psychiatric inpatient services, case management support, or specialized treatment modalities like EMDR or DBT. Be sure to check what your insurance plan covers.
9. If you decide to go Out-of-Network (OON), make a budget for yourself.
Let’s say you want to go OON, because you want a particular therapist, and they don’t accept insurance, or they don’t accept your plan. Make a budget for yourself. Think of what you could estimate paying per month for therapy.
I recommend people budget for 2 sessions a month, and no less. Monthly therapy is best for people who have done long periods of therapy already and are in maintenance mode. “Get a checkup from the neck up,” a client of mine used to call it.
10. If you can’t afford the full rate, does the provider offer a sliding scale?
Some providers, like us, provide sliding scale rates to see some of the therapists on our staff. The more experienced the provider, the lower the sliding scale fee will be.
Keep these things in mind if you’re exploring sliding scale:
Sliding scale rates will vary from one practice and provider to another.
Therapists consider several factors, when they offer sliding scale rates:
What is the lowest rate the provider will accept per session?
How is the scale ranked? Is it tiered? Is it based on individual salary, household income or dependents?
Are the sliding scale sessions limited? Can they be in-person or virtual?
11. Considering in-network options at Perez Therapy?
We’re very fortunate to be in-network with a few health insurances. Here are a list of the insurers we are paneled with:
Most commonly for employees of the University of Penn and Tower Health
Law Enforcement Health Benefits (LEHB), for Phila Police Department
We are working on our application to be in-network with Medicaid, and will soon be in-network with them! This will be a great opportunity for the communities that we serve.
Please verify which therapists at our practice accept these insurances. While many of the therapists at Perez Therapy accept these insurances, not all therapists do.
Looking for therapy with me, personally? I’m sorry to disappointment and say that at this point, I am only an out-of-network provider. Anyone that sees me, would pay my full fee. For in-network and sliding scale, therapists at Perez Therapy can be great options. I have limited my slots so that I can focus more hours on managing the company and providing close clinical supervision to the staff. (I hope you understand.)
Conclusion
The perfect scenario is:
You have health benefits.
Your issue is covered.
Your preferred therapist is in that network.
You are both available for in-person or virtual (whichever is your preference).
You really like this therapist.
If this is you, great! Consider yourself lucky. For some people, they have to invest a considerable amount in their mental health care. Other people have the luxury to pay out-of-pocket without great negative financial implications.
Just remember, sometimes if you want to use your health insurance coverage, it will take some time to find the right person who can take it. If your search leaves you with dead ends for in-network providers, determine if getting an out-of-network therapist is better instead. We hope that this list provides you with information on navigating the behavioral health insurance system. Whether we, at Perez Therapy, are the best therapist for you, is for you to decide, but I welcome you to consider any of the above, when selecting your new therapist and navigating in- vs out-of-network providers.
Please feel free to email me at Info@PerezTherapyLLC.com, if you have any questions about our practice. Me or someone from our team will be glad to help you with any questions you have. Whether we can provide you with a therapist or not, we hope to point you in the right direction. If there is anything that we missed or could better clarify, please let us know! Drop us a message, and we’ll be sure to get back to you.
About the Author: Felix A. Perez, LCSW is the owner and founder of Perez Therapy, LLC, a group psychotherapy practice in Fishtown, Philadelphia. Felix is a licensed clinical social worker and has 20 years of clinical and executive experience in behavioral health. Visit PerezTherapyLLC.com or social medias pages @PerezTherapyLLC for more information on our practice.
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