Such a simple question should have a simple answer. Will my insurance plan pay for marriage or family counseling? Yet the answer to this question is a resounding – maybe. When first-time clients call in and ask this question, the helper in us wants to say “yes.” We understand how hard it is to make that first call – to wrestle with the question, “do I call or do I see if it gets better on its own,” to face the fear of asking your partner to go with you, to agonize over how many times you’ve been in this bad place together and wonder if it can ever get better, to search for just the right therapist, to move from hope to despair and back again. We get it. We want to see you and help you get on a better track of relating and drawing close again. But first, we need to address the big elephant in the room – insurance. And the answer? It’s complicated. But stay with us, and we’ll try to break it down for you.
What’s the plan?
Once you’ve made the courageous decision to call and have spent quite a bit of time narrowing down who you want to see, the first question is related to your plan. “Is my potential therapist paneled with my insurance carrier and my specific plan?” This one is easy enough. You can check the therapist’s website. If they post financial information, you’ll know immediately. If they do not (there are many reasons this could be the case), a quick call to their office or your insurance company should clear that up. If you find that your preferred therapist is paneled with your carrier, the next two criteria come into play.
It’s all about the code
When a mental health counselor files for a client’s service, they must file two separate codes: a CPT code that identifies the length of service and who was in attendance and a diagnostic code that provides a diagnosis based on criteria from the Diagnostic and Statistical Manual of Mental Health Disorders (DSM 5 is currently in use.) The DSM is the insurance company’s Bible, as it presumably gives them some assurance of accurate therapeutic judgment and consistency of care when used properly by the treating therapist. So when asked, “Will my insurance cover my marriage or family counseling?” Here is where the “maybe” comes in.
The CPT applicable to family therapy (marriage therapy falls under this heading) is 90847. So the first question to ask your insurance company is if they cover this specific code. If the answer to this is yes, then you are halfway there. Unfortunately, many clients have asked their carrier this question and received an affirmative response, only to discover that after they received services, the company did not pay. How can this be? It’s because this code is only one-half of the equation. Even though the company may generally approve marriage or family therapy, they want to know the reason you seek treatment meets the definition of medical necessity. For that, therapists must supply a diagnostic code.
By their very definition, health insurance companies exist to provide financial assistance when their customers experience health issues serious enough to meet predetermined clinical criteria and receive treatment. However, they do not treat relationship issues or normal symptoms to life’s adversities. For example, let’s say you and your spouse have been in conflict for years, and you realize you must address your marriage before it’s too late. We would agree that marriage therapy is a wise. We would even understand how the emotional distance from your partner creates sadness and anxiety for you. But if the DSM 5 criteria for mental illness are not met, your insurance company may not regard your distress as a medical issue. Instead, they could argue that unhappiness is a natural response to the cycle of conflict between you. And they would have the DSM 5 to back them up. Even if you are in the middle of a divorce, sadness, anger, crying, and a certain level of anxiety are all normal. Are they treatable? Absolutely! Are they considered a medical necessity by your carrier? Not unless your daily functioning is markedly impaired.
But what happens if you meet the DSM 5 criteria for mental illness such as depression or anxiety? Then your chances for payment are higher. If your therapist assesses that your marital or family conflict exacerbates your condition, then a stronger case for medical necessity exists. However, suppose your mental illness is not related to relational strife. For example, suppose you are diagnosed with arachnophobia (fear of spiders). In that case, insurance will not likely pay for marriage or family therapy since it will not likely be the best treatment for your fear.
The 2 most common misunderstandings
We often have first-time callers with no mental health diagnosis seeking marriage or family therapy and wanting to file for insurance. After hearing their carrier’s standards for payment, people frequently understand that they do not meet the criteria and book their initial session, planning to pay out of pocket. However, some call other mental health practices hoping for a different response. On one occasion, a potential client requested therapy for herself and her husband and asked to file. After the therapist explained the requirements for filing, the caller stated she was depressed. After ruling out a current or previous diagnosis, for depression, the therapist asked about her symptoms. The caller responded she was sad. The therapist assured the caller of her desire to work with her and offered an assessment for depression to help discern medical necessity. Unfortunately, the caller became angry, made some uninformed accusations, and hung up. It was an unhappy ending for everyone. So what exactly is the misunderstanding here? That therapists are somehow mistaken or can change the situation if we tell them insurance won’t likely pay. Sadly, like you, our hands are tied. We don’t make the rules regarding insurance; insurance companies do.
Misunderstanding number two occurs when a potential client says insurance has previously paid for marriage therapy and expects payment this time even though they do not meet the criteria. When this happens, we believe they received benefits in the past but also realize it could be due to multiple possibilities. One possibility is that their insurance changed. Perhaps their previous coverage was far more generous than the coverage with their current plan. Although rare, some companies allow marriage and family therapy without a mental health diagnosis. That is why it is wise to check. Another reason may be that one partner was diagnosed with an Adjustment Disorder or other mental illness and wasn’t officially informed. Although this may seem odd, it isn’t uncommon. Because therapists are usually empathetic by nature, we default to helping. And if the desire to help combined with a lack of awareness of proper procedure is present, misdiagnosis can occur. I’ve heard well-meaning therapists say far too many times their clients were going through distress; therefore, they were adjusting and qualified for a diagnosis. However, even the often-used Adjustment Disorder has specific criteria for symptoms far more significant than the typical responses to a naturally painful situation. Usually, misdiagnosis results from a misunderstanding or lack of specific diagnostic training. But misapplying any diagnosis may be interpreted as insurance fraud which definitely helps no one.
How can I find out if I am covered?
To find out if you have benefits for mental health, call the Member Services number on the back of your card and ask if you have mental health benefits. If the answer is yes, ask if they cover CPT code 90847. If the answer to this question is also yes, and you have been diagnosed with a mental illness, ask the representative if you have coverage for your particular health challenge (not all diagnoses are covered, but that’s another story.) However, if you do not have a mental health diagnosis and are seeking treatment for marriage or family conflict, ask your representative if they cover the diagnostic code Z63.0 Problems in Relationship with Spouse or Partner or Z62.82 for Parent-Child Relational Problem. If the answer to any of these questions is no, you will need to pay out of pocket. But suppose you receive a “yes” to all of the above. In that case, you are in a much better position for payment as long as the relationally-oriented treatment is appropriate for the diagnosis. Because the insurance representative likely will not be aware of what treatments are appropriate, consider discussing this with your therapist.
Help! We aren’t covered, and treatment is expensive
Therapists are also healthcare consumers, so we share your concerns about the treatment price. Unfortunately, as with medical providers, education, ongoing training, professional requirements, and office overhead are at an all-time high. It hurts all of us. Yet we know from research that our mental health is critical for our physical health and daily functioning. Research also supports that our relational health is often key to our mental health. So, what do we do? At Family Renewal Counseling, we understand the dilemma and offer several options to reduce out-of-pocket costs while providing the care you need:
- One of our therapists is on insurance panels and will file for you when appropriate.
- We have additional therapists who are not on panels but offer a sliding fee scale. Anyone is welcome to apply, so feel free to ask your therapist.
- If your therapist is not on your insurance company’s panel, we will gladly supply you with a superbill to file for reimbursement. Many clients choose this method and report satisfaction with their reimbursement rate.
- We partner with several churches that offer financial assistance to their members. If your church has a care ministry, reach out to them or your pastor to ask about funds they may have set aside for congregational care. We will be glad to work with them.
- We offer mental health interns who work closely with supervisors on staff. The benefit for the client is they have the opportunity for “two sets of eyes.” While the intern receives highly specialized training based on Emotionally Focused Therapy, the most effective treatment for couples and families, clients reap the benefits. Specialized care at a lower cost – win/win.
- We are preparing some exciting workshops and groups for couples and families in 2023. These are also based on highly effective Emotionally Focused Therapy and are hard to find in our community. Stay tuned.
- If none of the options listed seem obtainable for you, many of our clients have found that parents and grandparents are often willing to help. If you are comfortable in your family relationships, you might consider them as a resource.
Although the question of insurance coverage covering marriage or family therapy is complicated, don’t let it deter you from seeking the restoration you and your loved ones long for. When you rebuild the relationships with each other, you increase your chance for mental and physical well-being as well as theirs. Everyone wins. If you are ready to make an appointment and need help understanding the maze of insurance, give us a call and we’ll walk you through it.