Insurance vs. Self-Pay - Questions to Consider

What is the Benefit of "Self Pay" versus Insurance?

Do you have a high deductible that must be met prior to insurance paying for counseling services?  

Do you want your insurance company to know your psychological diagnosis?  

Does the presenting problem for which you are seeking counseling meet the criteria for "medical necessity" that insurance companies demand in order to receive counseling services?  

If these are concerns for you, you may want to consider a 'self pay' option.  There is much to consider.  We hope the information shared below will be helpful for you.

There are pros and cons to using your health insurance benefits to pay for mental health care.

Pros:

If you have coverage to see the provider you choose, it will probably be cost effective to use your health insurance to pay for services.

Whether you are self-employed or work for an employer, you effectively pay a lot of money to have health insurance and it may make sense to get the most out of your benefit package by using insurance for therapy.

Cons:

There are many circumstances in which you might want to keep the fact that you are in treatment, as well as any information about that treatment, completely private between you and your therapist.

In order to qualify for benefits you must surrender a level of confidentiality to the insurance company that would otherwise remain between you and your therapist.

Insurance company employees may ask for personal information to determine whether or not they think treatment is warranted.  These employees decide if you are eligible for treatment, rather than leaving that decision up you and your clinician.

In order for insurance to reimburse your treatment you will receive a mental health diagnosis that goes in your permanent medical record.  This diagnosis constitutes a “pre-existing condition” that may be a disqualification from benefits in the future or may otherwise interfere with your coverage if you change plans.  Once you have used health insurance for mental health care you will also have to disclose your treatment history if you apply for life insurance and in certain other circumstances.

Insurance policies often limit the number of sessions you are allowed to attend each year.  They may or may not authorize more sessions based on what they determine is a “medical necessity”.  Your therapist will have little say in this decision and making your case may involve a lot of paperwork and footwork on your part.

Employers often change insurance companies to save money.  You may form a bond with your therapist only to find out that he or she is not a provider on your new plan.

Insurance rarely pays for marital or relationship therapy.  Instead, one partner will be identified as the “identified patient” and will receive a mental health diagnosis.  The insurance company will then authorize conjoint treatment for that person and his/her partner.

It could be a mistake to be dissuaded from seeking treatment because of the issues surrounding health insurance coverage for mental health.  If you do not want to use your health insurance and are limited in what you can afford, there are several avenues available to you. You can consider scheduling sessions less frequently or even abbreviating a session to meet your financial needs if your reason for counseling is not a crisis.  Many types of therapy do not necessitate weekly visits.  

here are a variety of ways to think about the purpose and process of therapy.  Insurance companies see therapy as treatment for a mental illness or condition and they treat the insured as patients who will either qualify or not qualify for the treatment.  This is not an invalid way to think about mental health care, but it is not the only way.  People are usually looking for relief from symptoms of some kind when they seek help.  Many come to find that therapy becomes a tool for enhanced personal growth, responsibility, and relationship satisfaction.  The medical model of diagnosis and treatment is no longer particularly relevant at that point.  Although you are entitled to use your medical benefits as you wish and are permitted by your insurer, you may ultimately decide that the flexibility and privacy afforded by paying directly is worth the extra cost.