Some gentle guidance on understanding your insurance benefits in plain English
Reading an insurance plan can sometimes feel like you’re in a nightmare where you’re sitting down for a test you didn’t study for. Everyone else around you is calm and prepared, but you look down at the first question and nothing makes sense, yet somehow you're the one who's supposed to know what "coinsurance" means.
If you've ever searched "therapist who takes my insurance” or took a look at your insurance’s provider directory, you might have found a list of people with no openings, got frustrated, and closed the tab. Don’t worry, your search doesn’t have to stop there. While working with in-network providers is often a smoother process, your insurance’s network does not have to be the fence you operate within. Many plans include out-of-network benefits, which can help pay for therapy with someone who isn't on your insurer's panel. Most people have never been told that, partly because insurance language sounds like it was written to be skimmed and surrendered to. So let's translate.
Is this post for me?
If you have a PPO or POS (Point of Service, typically a hybrid between PPO and HMO plans) plan, probably yes. HMOs and EPOs (Exclusive Provider Organization, which typically covers in-network providers only) often don't include out-of-network coverage, so call your insurer before getting your hopes up. If you have Medicaid or no insurance at all, you can still keep reading, and I'd encourage you to ask any therapist you're considering working with about sliding scale options.
The Vocabulary Decoded
Premium: What you pay every month just to have the insurance, whether or not you use it. Think of it as the subscription fee.
Deductible: The amount you pay out of pocket each year before your insurance starts contributing. If your deductible is $1,500, you cover the first $1,500 of eligible costs yourself. Many plans have separate deductibles for in-network and out-of-network care, so check which one applies. An additional note: deductibles reset every plan year (often, but not always meaning January).
Copay: A flat fee you pay per visit, like $30 per session. Copays are mostly an in-network thing.
Coinsurance: A percentage split after your deductible is met. If your plan covers 60% out-of-network, you pay the other 40%. This is the one that trips people up, because it's a percentage of the allowed amount, not necessarily of what your therapist charges as their fee for sessions.
Allowed amount: The most your insurance recognizes as the "reasonable" fee for a service. If your therapist charges $200 and your plan's allowed amount is $150, reimbursement is calculated from $150.
Out-of-pocket maximum: The most you'll pay in a year for covered care. After that, insurance picks up the rest. Out-of-network spending often counts toward a separate, higher max, or none at all.
In-network: Providers who've signed a contract with your insurance company, agreeing to its rates and rules.
Out-of-network (OON): Providers who haven't agreed to the insurance company’s contract. You have more freedom to choose your provider, and your plan may reimburse you for part of the cost.
Superbill: An itemized receipt your therapist gives you with the codes and details your insurer needs to process a reimbursement claim.
EOB (Explanation of Benefits): The statement your insurer sends after processing a claim. Despite the name, it often explains very little. It's not a bill.
How Out-of-Network Reimbursement Usually Works
You pay your therapist the full session fee at the time of your appointment..
Your therapist gives you a superbill.
You submit it to your insurance company, usually through an online portal.
If your plan has OON benefits, you get reimbursed for a portion of the cost of session, after your deductible is met and based on your coinsurance.
The key difference: you choose the therapist first and then see what your plan returns, rather than letting a provider directory choose for you.
A Clear Example
Say that I have an insurance plan with a deductible for out-of-network services of $1,000 and after I meet that deductible, the plan reimburses 60% of the allowed amount. For simplicity, let’s say the allowed amount matches my therapist’s $200 fee for sessions.
Payments for Sessions 1 through 5 go toward my deductible, and I receive nothing back yet.
After that fifth session, each $200 session earns me $120 back (60% of $200), so my net cost per session drops substantially from $200 to $80.
Everyone’s numbers will differ, but this is the basic math, and it's rarely as bleak or impossible as people assume.
Questions to Ask Your Insurance Company
If you’ve read this far and feel ready to look into your insurance plan’s benefits, here are a few questions that will be helpful to get answered when you call the customer service number on the back of your insurance card:
Do I have out-of-network mental health benefits?
Is there a separate out-of-network deductible, and how much of it have I met?
What percentage do you reimburse after the deductible?
Is reimbursement based on my therapist's fee or an "allowed amount"? What would this look like for CPT code 90837 (a 53+ minute session)?
Is there a limit on the number of sessions per year?
How do I submit claims, and how long do they take to process?
Write down the date, the name of the person you spoke with, and a reference number. Future you will be grateful to have that information.
A Few Honest Caveats
Reimbursement is never guaranteed. Your insurer makes the final call, and your therapist can't promise a specific amount.
Paying up front isn't accessible for everyone. If that's a barrier, make this known to a prospective therapist. Some offer reduced rates or accommodate different payment options.
The Takeaway
Therapy shouldn't hinge on whether the right person happens to be on an insurance panel. What matters more is whether they specialize in what you want to work on, whether their approach resonates with you, whether they have capacity to see you, and whether you feel safe and trusting of the relationship you’re building. If you find someone that checks those boxes and they aren’t in your insurance plan’s network, it’s worth a phone call to your insurance company and a little decoding using the vocabulary you just learned. You deserve to choose your therapist rather than settle for whoever's listed.
How Rooted Mosaic Handles Out-of-Network Benefits
I partner with Mentaya, a service that manages the superbill submission and coordination with insurance payors for you. This service does cost a 5% fee per claim submission. For those that prefer to handle seeking reimbursement on your own, I am happy to provide a superbill to you directly through my EHR’s portal. I’d love to connect and see if what I’ve shared helps break down some of the barriers to finding the right therapist. I offer virtual therapy for adults across Illinois and Colorado, as well as in person at my office located in Chicago’s River North neighborhood. Learn more about who I work with and if I’m the right fit for you!
This post is general information, meant for educational purposes. This post is not insurance or legal advice. Plans vary widely, so please verify your own benefits directly with your insurer.