Understanding out of network therapy benefits

When you are searching for a therapist, you are often trying to balance two things at once: finding someone who is the right clinical and personal fit, and making sure you can afford to see them regularly. That is where understanding out of network therapy benefits becomes important.

Out of network therapy benefits are a type of insurance coverage that may help you pay for sessions with a therapist who does not directly take your insurance. Instead of your therapist billing your insurance company, you typically pay for each session yourself and then seek partial reimbursement from your plan.

This model can feel confusing at first, especially if you are comparing it to therapy accepting insurance directly. However, once you understand how out of network coverage works and how to check your benefits, you can make a more confident decision about whether to work with a private practice psychotherapist who is an excellent fit for you, even if they do not participate in your insurance network.

How out of network therapy works

When a therapist is out of network with your plan, there is no contracted rate between that provider and your insurance company. The therapist sets their own fee, and you pay that fee at the time of service. After that, you can submit a claim to your insurance if your plan includes out of network therapy benefits.

Key terms to know

Understanding a few basic insurance terms will help you evaluate your options:

• Out of network deductible: The amount you must pay out of pocket for out of network services before your insurance starts to reimburse you. This is often separate from your in-network deductible and can be much higher. Some plans set out of network deductibles at $12,000 to $20,000, and sometimes there is no out of pocket limit at all for these services [1].
• Coinsurance: The percentage of the allowed amount your plan will pay after you meet your deductible. For example, if your plan reimburses 75 percent of the allowed amount, you are responsible for the remaining 25 percent. In one example, after meeting a $1,000 deductible, a client paying $100 per session could be reimbursed $75 per session with a 25 percent coinsurance [2].
• Reasonable and customary (or “allowed”) amount: The maximum hourly fee your insurance company decides is typical for a service in your area. They base reimbursement on this number, not on your therapist’s actual fee. Insurers often set this amount significantly below a therapist’s standard fee, which can result in balance billing and more out of pocket cost for you [1].
• Superbill: A detailed receipt that lists your diagnosis code, treatment code, session dates, and fees. Many out of network therapists provide a Superbill that you can submit to your insurance company to request reimbursement [2].

What the payment flow usually looks like

If you have out of network therapy benefits, your experience typically looks like this:

1. You choose a therapist you want to work with, even if they do not file insurance claims for you.
2. You pay the full session fee directly to your therapist after each session.
3. Your therapist gives you a receipt or Superbill at regular intervals.
4. You submit those documents to your insurance company, usually through an online portal or by mail.
5. After processing, your insurer sends you reimbursement for a portion of the fee, assuming you have met your out of network deductible.

Reimbursement often takes two to six weeks and you must front the full cost of therapy in the meantime [1]. That delay is important to consider when you are planning your therapy budget.

Why out of network benefits are harder to find

You might assume every plan includes out of network therapy benefits, but unfortunately that is not the case. Over the past decade, many commercial insurance plans have reduced or removed this coverage, especially individual plans purchased on the Health Insurance Marketplace. As of 2021, it is unlikely that many marketplace plan holders have meaningful out of network mental health benefits at all [1].

Even when these benefits exist, they often come with:

• Higher deductibles
• Higher coinsurance rates
• More balance billing because of low “reasonable and customary” rates
• Greater administrative burden because you must file your own claims

Between 2007 and 2017, prices and patient cost sharing for out of network psychotherapy increased significantly for adults, while in-network prices and cost sharing decreased. By 2017, patients were paying almost three times more out of pocket for out of network psychotherapy compared to in-network care [3].

These trends can understandably make you cautious. At the same time, many people still decide that using out of network therapy benefits is worthwhile because it gives them access to the right therapist and the type of care they want.

Positive reasons to consider out of network therapy

Despite the higher up front costs, there are several meaningful advantages to using out of network therapy benefits instead of restricting yourself to providers listed as in-network.

Access to a better fit therapist

You may have already noticed that it is difficult to find an in-network therapist who is accepting new clients, has appointments at times you can actually attend, and specializes in the concerns you are facing. This is a widespread issue. National data show that people with insurance often have more trouble finding in-network mental health providers than providers in other specialties, and many end up using out of network services and paying more out of pocket as a result [4].

Seeing an out of network therapist can be especially useful if you:

• Need a clinician with a specific specialty or niche expertise
• Live in an area where in-network therapists have long wait lists
• Want a particular approach or identity match that is difficult to find in your network

Out of network therapy benefits allow you to prioritize clinical fit and therapeutic relationship instead of limiting your search to the subset of providers who have contracts with your insurance company. Many people find that working with a therapy practice accepting new clients out of network lets them begin care sooner and with a therapist who truly understands their situation.

More flexible, personalized treatment

Insurance contracts often shape how in-network therapy works. Session length, frequency, and even treatment models can be indirectly influenced by what will be reimbursed. In contrast, out of network therapists are not tied to the same utilization rules.

Out of network therapy often allows for:

• Longer sessions when clinically appropriate
• More frequent sessions during periods of crisis or intensive work
• A broader range of treatment models, including approaches like harm reduction for substance use, which may not align neatly with insurance guidelines [5]

This flexibility lets you and your therapist design a treatment plan that is tailored to your needs instead of your plan’s billing rules. Many people feel that this leads to more personalized and effective care over time.

Greater privacy and control over your information

When you see an in-network therapist, your provider must send your insurance company detailed information to justify ongoing coverage. This can include diagnosis codes, treatment plans, and progress notes. For some clients, especially those concerned about employers, family members on the same plan, or the long term record of a diagnosis, that level of information sharing feels uncomfortable.

Out of network and self pay therapy limit the amount of clinical detail that gets shared. Your insurer generally sees only what is on your claim or Superbill, such as your diagnosis and session dates, instead of full notes from your appointments [5]. If you prefer a higher degree of privacy, this can be an important factor in your decision about how to pay for therapy.

Better access, even with high deductibles

If you have a high deductible health plan, you might already be paying mostly out of pocket for in-network therapy as well. For some people, the difference between in-network and out of network costs is smaller than it appears at first, especially when:

• You expect to meet your deductible anyway because of other medical expenses
• Your plan has comparatively good out of network reimbursement, sometimes up to 90 percent of the session fee [5]

In these cases, out of network therapy benefits can make working with a specific private pay therapist more affordable than you might initially think, particularly over the course of several months.

Important financial realities to consider

While there are clear positives to out of network care, it is also important to be realistic about the financial side so you can plan appropriately.

Higher costs and complex deductibles

For many plans, out of network therapy benefits come with:

• Significantly higher deductibles that must be met before any reimbursement starts
• Higher coinsurance percentages that leave you responsible for a larger share of each session
• No guarantee that your out of pocket costs will count toward the same maximums as in-network care

Some clients report out of network deductibles of $8,000 to $15,000 or more, which means therapy costs may not feel “covered” at all in practical terms [6].

In addition, insurers often apply only a portion of what you actually pay to your deductible. One person reported that with a particular insurance carrier, only about $110 of every $300 paid for out of network therapy applied to their deductible because of the insurer’s “customary” rate calculations, which made therapy unaffordable over time [7].

Understanding exactly how your plan calculates these numbers is essential before you commit to weekly sessions with an out of network clinician.

Upfront payment and reimbursement delays

When you use out of network therapy benefits, you pay your therapist first and then wait for reimbursement. Typical delays range from two to six weeks [1]. If your session fee is $150 or more and you attend weekly, you need to be comfortable with covering several sessions out of pocket while you wait for your insurer to process claims.

If cash flow is a concern, this is something to discuss openly with your therapist at the start. Some practices can space sessions apart, adjust frequency, or help you plan so that the financial impact is more manageable.

Administrative effort

With in-network providers, your therapist or clinic usually handles claim submission. With out of network therapy benefits, you are often responsible for:

• Downloading or collecting Superbills
• Uploading them through your insurance portal
• Tracking reimbursement and following up on denied claims

For some people, this is a reasonable tradeoff for the ability to see the therapist they prefer. For others, the paperwork and follow up feel like an added stressor. Thinking honestly about how much administrative work you want to take on can help you choose between in-network mental health therapy insurance options and out of network care.

How to check and use your out of network benefits

Before you decide how to proceed, it can be helpful to get a clear, written picture of what your specific plan will cover.

Questions to ask your insurance company

When you call the member services number on your insurance card or log into your plan portal, you can ask:

• Do I have out of network benefits for outpatient mental health therapy with a licensed psychotherapist?
• What is my out of network deductible, and how much of it have I already met this year?
• After I meet the deductible, what percentage of the “allowed amount” does the plan reimburse for CPT code 90834 or 90837 (typical individual therapy codes)?
• What is the “reasonable and customary” or allowed amount for therapy in my zip code?
• Is there a maximum number of sessions per year that the plan will reimburse?
• How do I submit claims, and how long does reimbursement typically take?

Some tools, like Zencare’s Out of Network Cost Estimate, let you input your insurance information and get a clearer estimate of what you might actually pay and be reimbursed for each session [2]. Using tools like this can help you make a more informed comparison between in-network and out of network options.

Talking with your therapist about fees and paperwork

Once you understand your benefits, you can speak with your prospective therapist about:

• Their standard session fee and any sliding scale options
• Whether they provide Superbills and how often
• Whether they can help you estimate what your net cost might be after reimbursement
• Payment methods, including whether you can use a Health Savings Account (HSA) or Flexible Spending Account (FSA)

Using HSA or FSA funds can make out of network therapy more financially manageable because you are paying with pre-tax dollars [8].

Many private practice psychotherapist offices are familiar with out of network benefits and can walk you through what to expect. Their goal is the same as yours: to ensure that you can access consistent, sustainable care.

When you understand your coverage and talk openly with your therapist about costs, you reduce financial uncertainty and can focus more fully on the work you are doing in therapy.

Comparing therapy payment options

As you evaluate how to access care, you are likely considering three main pathways: in-network therapy, out of network therapy using your benefits, and full private pay. Each option has tradeoffs.

For some people, finding a psychotherapist insurance accepted in-network is the best fit. Others decide that the combination of out of network therapy benefits and the ability to select a particular therapist offers the right balance of access, quality, and cost. Still others prefer a straightforward private pay therapist relationship with no insurance involvement at all.

There is no single correct choice. The right option is the one that lets you work with a clinician you trust, on a schedule you can sustain, at a cost that is realistic for you.

Putting it all together for your care

Out of network therapy benefits can feel complicated at first glance. Plans vary widely, benefits are not guaranteed, and the numbers can be discouraging if your deductible is high or your insurer applies low “customary” rates. At the same time, these benefits can open doors to care you might not otherwise access, including highly specialized therapists, more flexible treatment plans, and greater privacy around your mental health.

If you are weighing whether to use in-network coverage, out of network benefits, or private pay, you might find it helpful to:

• Clarify your clinical priorities, such as specialization, scheduling, and approach.
• Get clear written information from your insurer about both in-network and out of network coverage for therapy.
• Have a direct, transparent conversation with your prospective therapist about fees, Superbills, and your options for using insurance or paying privately.

By taking these steps, you can move from uncertainty to a more grounded understanding of your choices. That clarity can make it easier to start or continue treatment with confidence, knowing how your care will be supported financially as well as clinically.

References

1. (OpenCounseling)
2. (Zencare)
3. (PMC)
4. (NAMI)
5. (Ayre Counseling)
6. (NAMI, Reddit)
7. (Reddit)
8. (SF Stress & Anxiety Center)