All About Insurance

Understanding Your Health Insurance: In-Network vs. Out-of-Network Providers

Health insurance plans work with a specific group of doctors, hospitals, and other healthcare providers who have agreed to offer services at lower, pre-negotiated rates. These providers are called “in-network.” When you visit an in-network provider, your insurance company pays a larger share of the bill and your out-of-pocket costs are usually much lower. Providers who are not part of this group are called “out-of-network.” Our office is out-of-network for most plans, but many insurance policies still provide coverage for out-of-network care (often at a different level than in-network care). We have carefully set our fees using FAIR Health data, the independent benchmark most insurance companies use to determine “reasonable” charges for out-of-network services. This usually results in little or no balance bill for patients after insurance pays its share.

Key terms explained:

• Deductible: The total amount you must pay out of pocket each year for covered out-of-network services (from any out-of-network provider, not just us) before your insurance starts sharing the cost.

• Coinsurance: After the deductible is met, the percentage of the allowed amount you continue to pay (for example, 20% or 40%, depending on your plan).

• Out-of-Pocket Maximum: The most you will ever have to pay in a calendar year for covered services (including deductibles and coinsurance). Once you reach this limit, insurance pays 100% of additional covered charges for the rest of the year.

Example with a $1,000 Out-of-Network Deductible and 20% Coinsurance

Suppose your plan has a $1,000 out-of-network deductible, 20% coinsurance, and a $5,000 out-of-pocket maximum.

• Until you have spent a combined $1,000 on covered out-of-network care anywhere (our office, a specialist, an out-of-network lab, etc.): You pay 100% of the allowed amount; insurance pays nothing.

• After that $1,000 deductible is met: You pay 20% of the allowed amount and insurance pays 80%. For example, if our allowed charge is $200, you pay $40 and insurance pays $160.

• Once your total out-of-pocket spending (deductible + coinsurance from all out-of-network providers) reaches your $5,000 out-of-pocket maximum: Insurance pays 100% of any additional covered out-of-network charges for the rest of the year.

How to Check Your Own Coverage Quickly

Use our insurance checker here: https://mentaya.com/checkbenefits/o7CayWoFSRXr7T7qQry1

Another way is to look at the front of your insurance card for the member services phone number and website. Call or log in and ask for your out-of-network deductible, coinsurance percentage, and out-of-pocket maximum. Write the numbers down. Knowing these details ahead of time helps you plan with confidence and avoids surprises. We’re here to provide excellent care regardless of network status, and we’re always happy to answer questions so you can choose what works best for you!

How We Help You with Out of Network Claims

We are committed to providing high-quality mental health care without the constraints of insurance limitations. As an out-of-network practice, we offer a personalized and comprehensive approach to your mental well-being. As an out-of-network practice, we offer transparent and competitive fees for our services. While we are not in-network, many clients with out-of-network benefits find our personalized approach and comprehensive care well worth the investment. Contact our office to discuss your options and insurance. We are also proud to partner with Mentaya, a service that will submit out of network claims on behalf of patients who would like help with reimbursement.

Mentaya is perfect if you:
• Have out-of-network benefits
• Feel overwhelmed by superbills and insurance
• Have submitted superbills but failed to get any reimbursement
• Simply want to skip the hassle of paperwork!

Here's how it works:
1. Sign up for Mentaya: https://mentaya.co/inviteclient/o7CayWoFSRXr7T7qQry1
2. Our practice will enter your sessions into the platform.
3. Mentaya submits the claim and handles any insurance follow-up.
4. You get reimbursed by insurance!

Mentaya charges a 5% fee per claim, which includes handling any paperwork required, dealing with denials, and calling insurance companies. It's risk-free: They guarantee claims are successfully submitted, or a full refund of their fees.

If you prefer to submit your own claims to insurance to avoid Mentaya’s fee, just let us know.