1. What Are Out-of-Network Benefits?
Out-of-network benefits can help cover the cost when you work with a therapist who isn’t part of your insurance company’s network. Even if your provider is not directly contracted with your insurance, you might still be eligible for reimbursement!
2. Key Terms Explained
Deductible
Total Deductible: The full amount you need to pay for out-of-network services before your insurance begins reimbursing you.
Remaining Deductible: The portion of the deductible you have not yet paid.
Example: If you have a $1,000 remaining deductible, you must pay $1,000 out-of-pocket before reimbursement starts.
Important Note: You'll still need to file claims until you meet your deductible.
Copay vs. Coinsurance
Once you hit your deductible, the copay or coinsurance represents the portion of each session that your insurance will not cover.
Copay: A specific dollar amount (eg $20) of your session fee that insurance will not reimburse.
Example: If your plan has a $20 copay, and your session fees are $200, your insurance will reimburse an estimated $180 (subject to the allowed amount).
Coinsurance: A percentage (eg 30%) of your session fee that insurance will not reimburse.
Example: If your plan has a 30% coinsurance, your insurance will reimburse 70% of the allowed amount, and you’re responsible for the remaining 30%.
Important Note: Most plans will have either a coinsurance or a copay structure.
3. How Does the Out-Of-Network Reimbursement Process Work?
Upfront Payment:
For out-of-network services, you typically pay the entire session fee to your therapist upfront.Claim Submission:
After your session, Mentaya submits a claim to your insurance company, including the details of the service you received.Reimbursement:
Before Deductible is Met: You pay the full session fee until you have met your deductible.
After Deductible is Met: Your insurance reimburses a portion of the allowed amount according to your plan. You still pay the full session fee upfront, and insurance sends you reimbursement after you or your therapist submits your out-of-network claim on Mentaya.
Copay or Coinsurance: This represents the amount or portion of the session fee that insurance will not cover.
Example: Your therapist's fees are $200 per session, If your remaining deductible is $1,000 and your plan reimburses 70% of the allowed amount:
The first few sessions (until you spend $1,000 on out-of-network services) cost $200 per visit.
After the deductible is met, your estimated cost per session after reimbursement will be based on your coinsurance or copay (e.g., you may only pay approximately $60 of a $200 session if your coinsurance is 30%).