The short answer: sometimes, and usually not in the way people expect.
This confuses almost everyone, including people who work in health care. It is not because insurers are hiding something. It is because of how insurance defines what it pays for.
Insurance pays to treat a diagnosis
Health insurance covers medically necessary treatment of a diagnosed condition in one person. That framework fits individual therapy reasonably well. Someone has depression, treatment addresses the depression, the plan pays its share.
A relationship in distress is not a diagnosis. There is no billing code for “we cannot stop having the same fight.” So when couples therapy is covered, it is typically billed as family psychotherapy — code 90847 — as part of the treatment of one partner who does carry a diagnosis. That partner becomes the identified client, and the diagnosis goes in their permanent medical record.
Some couples are entirely comfortable with that. Others are not, particularly when it involves a diagnosis attached to a person who came in for help with their marriage. That choice belongs to you, and it is worth making deliberately rather than by default.
Your four questions
Call the member services number on the back of your insurance card and ask exactly these:
- Do I have out-of-network outpatient mental health benefits?
- What is my out-of-network deductible, and how much of it have I met this year?
- What percentage do you reimburse for CPT code 90847, and for 90837?
- Do I need preauthorization?
Write down the answers, the date, and the reference number for the call. Reimbursement disputes are much easier to win with a reference number.
What a superbill actually is
A superbill is an itemized receipt with the codes your insurer needs: the diagnosis, the service code, the date, the fee, and the provider’s license and NPI number. You pay your therapist directly, submit the superbill, and your insurer reimburses you according to your out-of-network benefits. Many PPO plans reimburse a meaningful share once the deductible is met. HMO and EPO plans often reimburse nothing out of network.
The in-network route
I am in network with several plans through Headway, which verifies your benefits and bills your insurer, so you pay only a copay or coinsurance. It is the most affordable route when your plan is on the list and the work fits what insurance will cover.
The honest summary
- If you want individual therapy and your plan is in network, use it.
- If you want couples work and you are comfortable with one partner carrying a diagnosis, ask about family psychotherapy coverage.
- If you would rather keep your relationship out of an insurance record, private pay gives you that privacy, and a superbill may still get some of it back.
None of these is the right answer for everyone. Ask the questions before the first session rather than after the third, and the money stops being a background anxiety while you are trying to do the actual work.
Annalis Garrido, LMFT is a bilingual marriage and family therapist working with couples and families in New York City and online across New York and Florida.More about her or book a free consultation.
This article is educational and is not therapy, diagnosis, or clinical advice for your situation. If you are in crisis, call or text 988.
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