Out-Of-Network Benefits Explained

Navigating insurance plans can be tricky— especially when we are trying to figure out how therapy fits into the mix.

What is the difference between In-Network and Out-of-Network providers?

Each insurance plan has “In-Network” providers who agree to accept a discounted rate for covered services under the health plan in order to be part of the network. Those that do not have a contract with your health plan are considered “Out-of-Network” and can charge you full price for their time.

However, some insurance plans offer benefits that help you cover the cost of “Out-of-Network” sessions. Some health plans, such as an HMO plan, will not cover care from Out-of-Network providers, except in an emergency.

What are Out-of-Network (OON) benefits and how do I use them for therapy?

If the therapist you’re seeing is not in your insurance network, then you will have to cover the cost of each session up front. However, your insurance (depending on the plan & company) may reimburse you for a part of the cost of your session. These are OON benefits.

A Guide to Using OON Benefits

Step 1

The first step to using your OON benefits is identifying four key parts of your plan. They are outlined below using the definitions from Healthcare.gov.

• Out of Network Deductibles - The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 out-of-network deductible, for example, you pay the first $2,000 of covered services with out-of-network providers yourself.

• Coinsurance - This is the percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. Let's say your health insurance plan's allowed amount for an office visit is $100 and your coinsurance is 20%.

  • If you've paid your deductible: You pay 20% of $100, or $20. The insurance company pays the rest.

  • If you haven't met your deductible: You pay the full allowed amount, $100.

• Allowable Amount - This is the maximum amount a plan will pay for a covered health care service. It may also be called “eligible expense,” “payment allowance,” or “negotiated rate.” If your provider charges more than the plan’s allowed amount, you may have to pay the difference.

• OON Out of Pocket Maximum - This is the maximum you pay for Out-of-Network services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

  The out-of-pocket limit doesn't include:

  • Your monthly premiums

  • Anything you spend for services your plan doesn't cover

  • In-network care and services

  • Costs above the allowed amount for a service that a provider may charge

Identifying what your plan covers for each of these is the first step to determining how your benefit works.

Step 2

Next, call your insurance company and ask the following questions:

1. What is my Out-of-Network deductible for outpatient mental health and have I met it?

2. Do I need a referral from an in-network provider to see someone Out-of-Network?

3. What is my coinsurance for Out-of-Network therapy sessions?

4. How do I submit claims for reimbursement?

Step 3

Ask your therapist for a “super bill.” This is a document that will provide your insurance company more information on the session cost & type to ensure that you are reimbursed for your care. Once you have this, you can submit your claim to insurance to get reimbursed!

Why are most therapists out of network?

Over 50% of U.S. therapists do not accept insurance & lots of folks ask us why. The thing is, insurance typically doesn’t offer good reimbursement rates to the therapists (unless they are psychiatrists). On top of the low pay, therapists have to spend multiple hours on the phone dealing with insurance companies for each client, which takes away from their time spent treating clients (and getting paid)! For this reason, most folks find that to run a sustainable practice— they cannot work with insurance companies.

How does this work on the Samata Health Platform?

A key benefit of our platform is seamless, built-in continuity of care for employees. 

Once you complete your last employer-sponsored therapy session on our platform, your account will automatically switch over to our public interface. There, you can continue booking sessions with your therapist as usual & without interruption! 

You will be responsible for payment for each session you schedule after using your full benefit. However, therapists on our platform all agree to treat Samata Health clients for $125 or less.

You can pay using a credit card, debit card or your FSA card, and you may also ask your therapist for a superbill to qualify for OON benefits!