The Essential Guide to Out-of-Network (OON) Benefits for Therapy: Everything You Need to Know

Navigating insurance coverage for therapy can feel like a tricky maze with no clear way out of. It’s easy to feel overwhelmed, especially when it comes to understanding out-of-network (OON) benefits. Many people don’t realize that they can still work with a therapist who doesn’t accept their insurance directly—and get reimbursed for some or all of the costs. This guide discusses how to use Out-of-Network benefits coverage to help you access a therapist who specializes in your needs. We will define the key terms, processes, and benefits of using OON coverage for therapy, so you can feel informed and confident about your options. 

This guide was written while the Affordable Care Act (ACA) is in place. Should the ACA be repealed or changed, it may change the information related to this guide.

Yes, most insurance companies will cover therapy if it’s considered “medically necessary.” Medical Necessity means you have a diagnosed condition from a licensed provider and you have a treatment plan designed to address that diagnosis.

Under the Affordable Care Act (ACA), mental health services are considered an essential benefit, and therefore ensures coverage if it meets criteria for medical necessity.  However, the specifics of your plan may determine if you can only see an in-network therapist, or if out-of-network therapists are also covered.

• In-Network (INN): These are providers who are contracted with your insurance company. The fee for therapy is a pre-set amount determined by your insurance company, and you are  responsible for any payment up to your deductible, or  copay/co-insurance, while the insurance covers the rest – the specifics of your deductible and co-pay/co-insurance are specific to your insurance coverage, so you would have to contact them for more information. The downside? These therapists must follow the insurance company’s rules regarding session length, type of therapy, and how many sessions are covered. Also, therapists must apply to be INN with an insurance company, so it limits who you get to see based on this.
• Out-of-Network (OON): These are licensed therapists who don’t contract with insurance companies. These therapists set their own fees and you pay them directly for their services. They can then provide you with a detailed receipt (called a superbill). You can then file a claim with your insurance for potential reimbursement, the specifics of which are specific to your insurance plan. The benefits of this is that you have more control over who you get to see, what happens in therapy, and how often/how long you see them for.

Your type of insurance plan determines your flexibility in choosing a provider.

• HMO (Health Maintenance Organization): You’re required to see in-network providers and often need referrals for specialists. HMOs typically do not cover OON services.
• PPO (Preferred Provider Organization): Offers the flexibility to see OON providers. You’ll pay upfront and can submit claims for partial reimbursement.
• POS (Point of Service): A hybrid plan combining features of HMO and PPO plans, sometimes offering limited OON coverage.

OON providers often specialize in areas like trauma, eating disorders, or OCD, offering expertise not always available in-network.

1. Ask Your Insurer About OON Coverage:
   Use your insurance card to find the customer service number. Ask the following questions:
• Do I have OON benefits for therapy?
• What is my OON deductible, and how much of it have I met?
• What percentage of the session fee will I be reimbursed?
• Are there any session limits?
• What documentation do I need to submit a claim?
2. Pay Your Therapist Directly:
   OON therapists typically require payment at the time of service.
3. Obtain a Superbill:
   Ask your therapist for a superbill, which includes:
• Your therapist’s name, license, and NPI number.
• Diagnosis and treatment codes.
• Session dates and costs.
4. Submit Your Claim:
   Follow your insurer’s claim process. Many have online portals for uploading superbills.
5. Receive Reimbursement:
   Reimbursement amounts vary based on your plan. For instance, if your insurance allows $100 for therapy and covers 70%, you’ll receive $70—even if your therapist charges $150.

Contact your insurer for an explanation and details on their appeals process. Sometimes, additional documentation from your therapist can help.

Many plans do. For example, your in-network deductible might be $500, while your OON deductible is $1,500.

• Higher Quality Care:
  OON therapists aren’t restricted by insurance policies, allowing them to provide comprehensive and specialized treatment. Furthermore, they are oftentimes more specialized in their field and can offer more in-depth services.
• Freedom to Choose Your Therapist:
  You’re not limited to a directory of in-network providers, giving you access to someone who truly fits your needs.
• More Time in Session:
  Without insurance dictating session lengths, many OON therapists offer extended or flexible session times.

Understanding out-of-network benefits empowers you to access high-quality, personalized care without being constrained by insurance networks. While it requires extra steps to submit claims, the benefits of working with an OON provider—like specialized care, shorter wait times, and greater flexibility—are well worth it. If you’re considering therapy with an out-of-network provider, reach out to your insurer and your prospective therapist to ensure you’re clear on your options.