Before a first mental health appointment, ask your insurer five things: whether you have out-of-network mental health benefits, what deductible applies, what share it pays and of what amount, whether anything needs approval first, and how claims get filed. Those answers explain most of the gap between what a visit costs and what you get back.
Part of our guide: Getting Started With Mental Health Care
Plans differ a lot, so a general answer from a website or a friend may not apply to you. Use the number on your member ID card, and ask for the behavioral health or mental health benefits line if there is one. The call is easier with the questions in front of you, so here they are in the order that tends to work best.
Before you call
Have these ready, so the representative can answer about your plan and the care you are considering:
- Your member ID and the policyholder's name and date of birth
- The type of care you want: a psychiatric evaluation, medication follow-ups, therapy, or psychological testing
- The clinician's name and license type, if you know them
- Your plan's Summary of Benefits and Coverage. HealthCare.gov says you can ask your insurer or group health plan for a copy at any time
- Somewhere to write down the date, the representative's name and a call reference number
The core questions
This table covers what most people need. The right-hand column explains why each answer changes your costs.
| Ask this | Why it matters |
|---|---|
| Do I have out-of-network benefits for outpatient mental health care? | If the answer is no, reimbursement may not be an option unless an exception applies. |
| What is my out-of-network deductible, and how much have I met this year? | A deductible is what you pay for covered services before the plan starts to pay. Ask whether your plan has a separate one for out-of-network care. |
| After the deductible, what percentage do you pay? | This is your coinsurance. New York regulators note that cost-sharing will usually be higher for out-of-network services. |
| What is the allowed amount for this service, and how do you calculate it? | The percentage applies to the plan's allowed amount, which may be lower than the clinician's fee. You may owe the difference. |
| Does out-of-network spending count toward an out-of-pocket limit? | HealthCare.gov's definition of the limit excludes out-of-network care and costs above the allowed amount, so do not assume you are protected by a yearly cap. Ask how your plan handles it. |
| Is prior approval or a referral required? | Your plan may require preauthorization for certain services. It is also not a promise of payment, so ask what else applies. |
| Are there limits on visits or on how often I can be seen? | This helps you plan for ongoing care, such as weekly therapy, and not only the first visit. |
Questions specific to the type of care
Coverage can vary by service, even within one plan. Add whichever of these apply to you.
Psychiatric evaluation and medication visits
- Is a first evaluation paid differently from follow-up visits?
- Are medications I may be prescribed on the formulary, and do any need prior approval? Your clinician can help with specifics once a plan exists.
Therapy
- Do you reimburse this license type? Ask about the clinician's exact credential, and about pre-licensed or supervised clinicians if that applies. This guide to clinician credentials explains the letters.
- Do couples or family sessions fall under the same benefit?
Testing and specialized treatments
- Is psychological or ADHD testing covered, and does it need approval first? Is ADHD Testing Covered by Insurance? goes further on that question.
- For treatments such as Spravato or ketamine, ask what the plan requires before you schedule. This article on coverage for those treatments has more detail.
Telehealth
- Do you cover video visits at the same rate as in-person visits?
- Does it matter where I am during the visit? NIMH advises people to confirm telehealth coverage, because policies vary. Telehealth Across State Lines covers the location question.
Questions about getting paid back
Coverage is only half the picture. The other half is how the money actually reaches you.
- Who submits the claim, me or the clinician's office?
- Where do I send a claim, and is there a form or online portal?
- Is there a filing deadline, counted from the date of service?
- What must the paperwork include? Ask whether diagnosis codes, service codes and the clinician's ID numbers are required.
- How long does processing usually take, and how is reimbursement paid?
If you will be submitting claims yourself, What Is a Superbill? walks through the paperwork. For the bigger picture of how these benefits work, read How Out-of-Network Mental Health Benefits Work in New York.
One question most people skip: who regulates my plan?
Ask, "Is my plan fully insured or self-funded, and which state's rules apply?" The answer can decide which protections you have.
New York's Department of Financial Services says its mental health access rules apply to individual and group policies subject to New York law, and do not apply to self-funded ERISA employer plans. It also says that if you or your employer buy a policy in another state, that state's rules apply. An employer's HR or benefits team can often confirm this if the phone representative cannot.
If you cannot find an in-network clinician
This matters if you would prefer to use your network but cannot get seen. For policies subject to New York law, regulators say you are entitled to a first outpatient mental health appointment within 10 business days. If the insurer cannot find an in-network clinician in the required time after you file an access complaint, it must approve a referral to an out-of-network clinician who meets the requirements and does not charge excessive or unreasonable rates. Your cost-sharing is then the same as in-network.
The steps and limits are specific, so read the state fact sheet and ask your insurer how it applies to you. These rules phase in as policies renew, so ask about your plan's dates too.
What to ask if the answer is no
A representative's answer on the phone is not the last word. Ask:
- Can you send that in writing, or show me where it is in the plan documents?
- What is the reason for the denial or limit?
- How do I appeal, and by when?
In New York, regulators say you have 180 days to appeal with your insurer, and some denials, including those about medical necessity or out-of-network services, can go to an independent external appeal with its own deadlines. The same page says New York's independent Behavioral Health Ombudsman can help with questions, complaints and appeals. Your plan's rules may differ, and this is general information, not legal advice.
Keep a record, and treat it as an estimate
Write down what you were told, and ask for anything important in writing. Even a clear answer is not a guarantee, because payment depends on the claim, your plan's terms and how the service is coded. Budget using the lower end of what you might get back, and check again when your plan year changes.
Also ask the clinician's office for its fees and policies, because your insurer will not know them. If you plan to pay without using insurance, you can usually ask for a Good Faith Estimate before your visit. If you plan to submit a claim, those federal estimate and dispute rules may not apply.
How this works at Mind Body Seven
Mind Body Seven is an out-of-network practice and does not accept Medicare or Medicaid, including managed Medicaid. For many clients with Cigna, Aetna or BCBS plans, it files out-of-network claims for them. For other carriers, such as UnitedHealthcare, superbills are available in the patient portal. Details and the benefit questions the practice suggests asking are on the fees and insurance page, and this page explains out-of-network psychiatry. You can also call (212) 621-7770 with questions before you book.
FAQs
Can I call my insurer without giving a reason for seeking care?
Yes, for the most part. You can usually ask about benefits by describing the type of service, such as outpatient therapy or a psychiatric evaluation, without describing your symptoms.
Who can call on my behalf?
Ask your plan what authorization it needs before it will discuss your coverage with someone else, such as a spouse or adult child. Ask separately about calling for a minor on your plan.
Should I call again if I change jobs or plans?
Yes. Benefits, deductibles and networks can all change with a new plan or a new plan year. Repeat the core questions, and check that any approval you received still applies.
What if two representatives give me different answers?
Write down both answers with their dates and reference numbers, then ask for the answer in writing or a copy of the plan language. The written plan documents are a better guide than a phone summary.
