How out-of-network reimbursement works for therapy in Arizona
Private pay doesn't always mean you carry the whole cost.
When people hear that a therapist doesn't take insurance, many assume that means insurance is out of the picture entirely. Often it isn't. A lot of plans, especially PPO plans through employers, include out-of-network mental health benefits. That means you pay the therapist directly, and then your insurance reimburses you for part of the cost.
It isn't automatic, and it isn't the same for everyone. But it's worth understanding before you decide whether private pay therapy is within reach, because for some people the difference is significant.
The basic idea
With in-network care, the therapist bills your insurance and you pay a copay. With out-of-network care, the order flips. You pay for the session up front, a claim is submitted to your insurance with the details of the visit, and your plan sends you back whatever it covers.
The document used for that claim is often called a superbill. It lists the date of service, the type of session, the therapist's license information, and a diagnosis code. Your insurance needs that information to process the claim.
What decides how much you get back
Every plan is different, but a few pieces usually determine the result:
Whether you have out-of-network benefits at all. Many PPO plans do. Many HMO and EPO plans don't.
Your out-of-network deductible. This is often separate from your in-network deductible, and you may need to meet it before reimbursement starts.
Your coinsurance. After the deductible, plans often reimburse a percentage of what they consider the allowed amount for the session.
The allowed amount. Insurance decides what it thinks a session should cost, which may be less than the actual fee. Reimbursement is based on that number, not on what you paid.
This is why two people seeing the same therapist can get very different amounts back. One may be reimbursed a large share of each session once their deductible is met. Another may get little or nothing until much later in the year.
Timing matters too. Deductibles usually reset in January, so someone starting therapy in the fall may already have met much of theirs through other care that year, while someone starting in January may pay more out of pocket at first. Some people also use a health savings account or flexible spending account to pay for sessions, which can lower the real cost even when reimbursement is limited. It's worth checking whether yours allows it.
How it works in my practice
I'm private pay for Arizona clients, and I work with Mentaya to make the insurance side easier. Mentaya can check your out-of-network benefits before we start, so you have a rough idea of what to expect, and it submits claims to your insurance for you after sessions so you don't have to fill out forms yourself. Whether you're reimbursed, and how much, still depends on your plan.
You can check your benefits right now on my fees page. It takes a few minutes and doesn't commit you to anything.
A note on diagnosis
To use out-of-network benefits, a diagnosis goes on your superbill, because insurance requires one for reimbursement. If you'd prefer not to involve insurance at all, that's your choice, and many people pay privately for exactly that reason. We can talk about what makes sense for you during the consultation.
Questions worth asking your insurance
If you'd rather call your plan directly, these questions will get you most of the way:
Do I have out-of-network benefits for outpatient mental health?
What is my out-of-network deductible, and how much of it have I met?
What percentage do you reimburse after the deductible?
Do telehealth sessions qualify?
Getting started
Sessions are $200 for individual therapy and $250 for couples, by video anywhere in Arizona. If cost is part of what you're weighing, that's a completely reasonable thing to bring up on the free call. See fees and benefits, or book a free 15-minute consultation.
