What are all these terms? Understanding the language of health insurance!
Updated: Dec 12, 2021
Are you someone who is currently in therapy and paying cash for the sessions? Do you also have health insurance through your employer but have been told that the company does not cover or reimburse for Mental Health Care? There is a federal and state policy that was passed in 1996 that requires many health insurance companies to reimburse for mental health care in the same way they do for other medically necessary appointments ( like a doctors visit, surgery etc.) This is called the The Mental Health Parity and Addiction Equity Act .You may be able to work with your therapist to request that your insurance cover your therapy & this site is designed to support you and your therapist in this process.
Here's a list of the language you will read and most likely need to use:
In-Network Provider: A therapist who is registered with an insurance company to provide service & receive payment for those services. The amount the therapist is paid is determined by the health insurance company's rate.
Out of Network Provider (OON) : a therapist who is NOT registered or contracted with an insurance company to receive payment. OON providers charge cash or what is called "out of pocket" fees at a rate determined between you and the therapist.
Reimbursement: The amount of money that is paid by the insurance company. It is considered a reimbursement because it is paid AFTER the service is provided. A reimbursement can either be paid to your therapist directly or to you the client.
Single Case Agreement: a written agreement or contract that is created between your insurance company and your therapist. It only applies to you ( single) and states that your insurance will pay for your mental health coverage at a rate determined by the insurance company. Sometimes this includes you paying a co-pay.
Co-Pay: the amount that you (the client) is expected to pay alongside the fee that the health insurance company pays your therapist. This will be a set amount.
CPT Code : Current Procedural Terminology. Your insurance may ask your therapist "what CPT codes" they are using. These are the numbered codes that they will use to bill for the mental health sessions. Common CPT codes for mental health/ behavioral health care can be found in the Info-Graphic " How-To Guide for Therapists Using Single Case Agreements" on this site.
Diagnosis Code: These are the codes ( a combination of letters and numbers) that your therapist will need to provide that describe and label the diagnosis for your mental health condition. Diagnosis is a very debated subject and some therapists can collaboratively decide what to share with your insurance with you.
You can read more about Diagnosis and the DSM debates in Mad In America which provides a social justice lens to this discussion.
Center for Medicaid and Medicare Services. The Mental Health Parity and Addiction Equity Act (MHPAEA). Retrieved December 7, 2021 from: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet
Gnaulati, E., (2018, April 30). The woeful underfunding of psychotherapy by health insurers. Mad In America. Retrieved December 9, 2021, from https://www.madinamerica.com/2018/04/woeful-underfunding-psychotherapy-health-insurers/.
Joly, Vinodha.(February 17,2017) Single Case Agreement (SCA) With Insurance Companies. Retrieved December 7, 2021 from https://vinodhatherapy.com/blogs/2017/2/23/single-case-agreement-sca-with-insurance-companies