Therapy and insurance... how much are you paying?

[Anonymous]

I knew that most providers were out of network and went in realizing I'd have to pay 50%. Months in and I just got my explanation of benefits that says it's not actually 50% of what I'm paying, it's 50% of what they think therapy is worth (roughly $70 vs. $200). So, once I hit a completely separate deductible because the out of network deductible is completely separate and higher than my normal deductible, I'll start getting roughly $35 out of every $200 reimbursed. Is that typical? We could not find a provider in network with the right specialty and DS was reluctant so I wanted to go with a provider that came highly recommended.

[Anonymous]

That's pretty identical to what I found. I paid the crazy prices for a little, while continuing to look for someone in network. After about 9 months I found someone in network- definitely not as good, but only $15 a week so it is what it is.

[Anonymous]

Yes, the out of network is a percentage of their fee schedule, not actual charges.

[Anonymous]

Yes, unfortunately this is normal. It’s a miracle if you even come close to hitting the astronomical out-of-network deductible before the end of the year to receive that meager morsel of insurance coverage. This is a huge problem in our country and I am sure this is why so many kids don’t receive treatment.

There was a father in my parent management training class who was in tears because his son desperately needed treatment but he could no longer afford it because he was being laid off. A child can get proper coverage for a broken arm, but only pennies for mental health. Something is terribly wrong with the system.

It is rare to find therapy in network and when you do, it’s sub-par, so what’s the point in looking for it? Everyone knows the effective therapists don’t accept in-network insurance.

[Anonymous]

Yeah, I never even both to look for one in network anymore. Most don’t seem to take insurance at all so I’ve filed and get a percentage back. It’s a shame. In a more progressive society, we would have gotten help 15 years ago and spared us all a lot of misery and bigger bills.

[Anonymous]

You can ask for an exemption sometimes it’s granted when there’s no one within a certain geographic radius.

[Anonymous]

I did the math on our out of network -- between our copay and deductible I would have had to spend $8000 out of pocket before I saw a nickel of reimbursement on a $220 an hour psychologist. That is for a "gold" plan in the Obamacare marketplace. The good thing is that for some amazing reason they do cover the 2x weekly psychotherapy before deductible (for an in network provider). This is actually helpful.

However, we just switched to new insurance with a much lower deductible which is supposed to be a "better" federal health insurance plan. For the same provider, I will pay the deductible plus a $25 copay. That means instead of paying nothing to his psychotherapist, I will end up paying $1550 a year. For the psychiatrist, on 4 med check visits at $275 each out of network, I get 35% reimbursement of UCR which probably will amount to about $50 on a $275 visit.

I think out of network and in network OOPs are separate ($5K each), so I don't think I will hit either OOP and even if I did, I would still be responsible for the balance billing.

I tried to get an in network psychiatrist at Children's, but I couldn't even get them to return my call despite returning an intake packet multiple times and going down to the office in person.

[Anonymous]

We are lucky. It’s an HMO so no OON coverage but we found a social skills group in network, as well as family and individual therapists. We have a $1500 deductible so I hit that on neuropsych and it will reset next year, but just $25 co pays at the moment.

[Anonymous]

We spent $7000 on therapy/psychiatry last year and I got back about $600 due to the deductible and the allowed amount. This year, our insurance (large government contract employer of many with really crappy options) out of network deductible changed to $10,000, so there’s no way we will hit it. It such but we have such a good care team, I won’t consider switching.

[Anonymous]

*it sucks

[Anonymous]

I'm on the DC HealthLink (ObamaCare) for my small employer in DC. The out of network deductible is so high, and the premiums are so much higher than my HMO, that it just wasn't worth it. I'd never hit the separate OON deductible.

[Anonymous]

Normal. We can only go to in-network providers or we pay it all.

[Anonymous]

Anonymous wrote:I knew that most providers were out of network and went in realizing I'd have to pay 50%. Months in and I just got my explanation of benefits that says it's not actually 50% of what I'm paying, it's 50% of what they think therapy is worth (roughly $70 vs. $200). So, once I hit a completely separate deductible because the out of network deductible is completely separate and higher than my normal deductible, I'll start getting roughly $35 out of every $200 reimbursed. Is that typical? We could not find a provider in network with the right specialty and DS was reluctant so I wanted to go with a provider that came highly recommended.

One thing you can try doing is appealing the situation to the insurance company and ask them to treat the OON provider is in network because their in network doesn’t have the right specialty. It may raise your reimbursement a tiny bit, although you will still be responsible for the balance bill from your OON provider. It may also enable you to hit an in network deductible or cap. (although you will likely have to track that and argue for it as well.)

[Anonymous]

I gave up putting in claims. On $11,000 worth of bills. in a year, we got back around $400. Not even worth the time I spent filing the claims every month. I think this is a phenomenon of expensive cities. When we lived elsewhere, it was more common for mental health professionals to be in-network.

[Anonymous]

$25 in copay.