Navigating and utilizing your insurance policy can be tricky and confusing. It's likely that nobody ever explicitly taught you how to understand your benefits, or that it was too much information to grasp at the time. If you have benefits, I want to help you make the most of them.
Who am I in-network with?
I am considered an in-network provider for
- Regence BlueShield
- First Choice Health Network
- Kaiser PPO
- Lyra EAP
I am considered in-network with any subsidiaries of these, such as Meritain Health.
Your insurance provider needs information about me to verify coverage. Here are the answers.
If your insurance provider wants to verify whether I am an in-network provider, or needs additional information for pre-authorization, it is typically this:
- My name: Diana Hu
- My tax ID: 85-2338195
- The services I provide: outpatient mental health/therapy, or psychological assessment
Key Insurance Terms
These terms will come up repeatedly in your understanding of your insurance benefits, so here is an overview of what they mean:
- Insurance Provider: This is the company that provides your health insurance coverage. This can typically be found in the top lefthand corner of your insurance card. Common insurance companies include Regence BlueShield, Premera BlueCross, Aetna (or Meritain), FirstChoice Health Network, and others.
- Patient ID: This is your unique identifier that links you to your benefits. It typically consists of numbers and letters, and is at least 10 characters. Any use of your insurance will require this ID, your name, and your date of birth to verify benefits.
- Deductible: This is the amount that you will have to pay before your insurance benefits fully kick in. (This varies widely, but is typically between $1,500 and $3,500.) Appointments that go towards your deductible will be charged at your provider's insurance-negotiated rate, which is typically a discount from their standard rate. (For example, my standard rate is $180, but insurance-negotiated rates are lower.)
- Co-pay: This indicates what you will be responsible for after meeting your deductible. (This is typically $20-$50.)
- Co-insurance: This is an alternative to a co-pay, and indicates a percentage of the visit that you will be responsible for. (This is typically 10-30%.)
- HSA funds: This is a debit-like card that holds funds that you use specifically for medical purposes. You and your employer contribute to this balance, and it can be used for in-network or out-of-network visits, including mental health.
- Out-of-Pocket Limit: This indicates the maximum that you will ever pay for medical expenses in the period coverage by your insurance. Once you reach this limit, services are fully covered. Most plans will count what you paid for your deductible and co-pay/co-insurance towards this limit. Some plans also count anything you pay for out-of-network services towards this limit. To understand what is included, refer to your insurance handbook or call your insurance provider.
- Pre-authorization/Prior Authorization: Some services need to be approved by your insurance provider in order to be covered. Typically, outpatient therapy visits (such as the ones provided here) do not require pre-authorization. In some cases, psychological assessment services do require pre-authorization. The easiest way to find out if you need authorization for the services you have in mind is to call your insurance through the phone number on the back of your insurance card.
Example Insurance Usage
To better understand how insurance benefits might work, here is an example:
Let's say that your benefits include:
$25 visit copay
$4000 out-of-pocket maximum, including out-of-network costs
Let's say that you injured your knee playing sports, and need physical therapy. Your physical therapist is in-network, and their insurance-negotiated rate turns out to be $100. You go to this physical therapist 10 times until your knee is healed. You will have paid $1,000 for these sessions, and it will count towards your deductible. You use your HSA card for this. You now have $1000 left of your deductible, and $3000 left of your out-of-pocket max.
Let's say that a few months later, you decide to start therapy. This therapist is out-of-network, and their rate is $150 per session. You will be responsible for all of that rate, but can still pay using your HSA card and it will count towards your out-of-pocket max. You see this therapist for 6 sessions before you decide it isn't a good fit. You now have $1000 still left of your deductible (since they were out-of-network), but only $2100 left of your out-of-pocket max ($3000 minus the $900 for the 6 sessions).
You then switch to an in-network therapist to continue treatment. Their in-network rate ends up being $100 (how convenient). You like this therapist, and see them for 14 sessions. After paying 10 sessions at the $100 rate using your HSA card, you have hit your deductible, and your fee drops to $25 (your deductible) for the subsequent 4 sessions, which you continue to charge to your HSA card. At this point, you have no remaining deductible to meet, and your remaining out-of-pocket amount is $1000 ($2100 minus the $1100 for the 14 sessions).
Finally, you decide to also complete a psychological evaluation to clarify what might be going on. The testing psychologist is out-of-network, and charges $200 per hour. As you meet, you pay for 5 hours of their time ($1,000), but then meet your out-of-pocket limit. You no longer need to pay anything yourself, as your insurance will cover any remaining medical costs for that year.
What should you know about your benefits before starting therapy?
To be financially prepared, here is a list of helpful things to know:
- Is this in-network, or out-of-network? (See the list of insurance providers I am in-network with on my Fee page.)
- If it is in-network:
- How much of my deductible is left?
- How much is my copay or co-insurance for mental health services?
- How much of my out-of-pocket maximum is remaining for the year?
- If it is out-of-network
- How much of my out-of-network deductible is left?
- How much is my copay or co-insurance for out-of-network mental health services?
- Do out-of-network visits count towards my out-of-pocket maximum?
- If so, how much of the out-of-pocket maximum is remaining for the year?
These answers may be found through your insurance provider's handbook or online portal. It is also possible to call the phone number on the back of your insurance card to talk to a representative.
What else should you know about your benefits before starting an assessment?
Psychological assessment services generally follow the same procedure with insurance as therapy services, but with a few extra components.
You'll still want to ask the questions about deductible, copay or co-insurance, and out-of-pocket maximum as you would for seeking therapy services. However, it's a good idea to also ask the following:
- Do I need pre-authorization for an ADHD mental health evaluation?
- If I need prior authorization, how do I obtain it?
- What is my copay or co-insurance for the CPT codes 90791, 96132, 96133, 96136, and 96137? (It should be similar to that of other mental health services, but it can be helpful to check specifically the codes that will be billed.)
With this information, you can then use this Assessment Charge Calculator to estimate what you might expect to pay for all of the assessment-related services.
The exact balance will depend on what your insurance sets as their allowable amounts for any given service, the number of units (aka the amount of time) needed for your specific case, and if the obtained insurance information is accurate.