When most people come to therapy, they aren't thinking about which of their concerns may or may not be covered by their health insurance. Nor do they think about just how many sessions and what length of session their health insurer will agree to cover. Most therapists don't think about these issues much, either-- not until they are audited by an insurance company and, in the worst-case, have to pay the insurer back for sessions that did not fit their criteria. When using your health insurance for therapy, it is important to understand the difference between what is covered and what is not, as well as how the conditions change when an insurer is involved.
The focus of therapy
Psychotherapy (aka therapy), when covered by health insurance, is a treatment that has been deemed "medically necessary" by your mental health provider. According to health insurers,medical necessity is a term that essentially means that you need a treatment for your health to be restored (i.e., symptoms to reduce). The focus of therapy is on the teaching of coping skills and alternative modes of thinking, centered on the symptoms you reported.Traditional psychotherapy is designed to meet the goals of the individual client, whether or not there is a mental health diagnosis. Personal insight, self-esteem, relationship problems, distress at work or school, family discord, recovery from religious abuse, finding the right career,exploring your existential fears, resolving your fear of commitment, addiction to the internet orsexualized media, and heart-break over a cheating spouse are examples of things that typically are not covered by health insurance.
The length of sessions
Traditional psychotherapy was designed around the 55 minute treatment session. More recently,many health insurers have put into place guidelines for 55 minute sessions, but generally expect that treatment sessions are much shorter (e.g., 40minutes). In fact, when more 55 minute sessions are used, it is common for therapists to receive letters from health insurance companies, stating that they are using more 55 minute sessions than their peers. Whether or not this is true is difficult to ascertain, as there is not current scientific literature on the session time-limits used by therapists. The message is both clear and implicit: Shorten the session time.Fifty-five minute sessions are generally allowed for trauma-focused therapy (e.g., EMDR) and other treatments that specify the need for such sessions. Since most (if not all) therapists were trained on 55 minute sessions, the ethics of shorter sessions may not be fully established. Most of the empirical studies of various psychotherapeutic treatments include 55 minute sessions.Thus, therapists are left to face an ethical bind: Shorten the session despite the lack of evidence or risk not being paid.
Number of sessions
While official session limits do not exist, therapists find themselves in a precarious situation with regard to the number of sessions to have with a client. There is great variability in the amount of sessions attended by different clients. Some come for 4-6 sessions and others spend years talking with the same therapist, as they sort out ingrained interpersonal patterns and toxic relationships (neither of which are covered by insurance).When you use your health insurance to cover your sessions, there is an expectation that you will show progress and graduate therapy in 12-24 sessions. When you show enough progress,your therapy is not longer "medically necessary." If you fail to show progress within 12 sessions,your condition is considered treatment resistant and most health insurance companies expect a therapist to stop providing a treatment that is not working. We can offer another therapeutic approach, if we have one (e.g., Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, Eye Movement Desensitization with Reprocessing), but ultimately, our time together will end with you feeling better enough that you no longer meet the criteria of a specific disorder or a discussion in which one or both of us decide that the treatment isn't working.
Prevention and Maintenance
If you ask a mental health therapist, most of us would probably agree that psychological and therapeutic interventions are effective as prevention measures against the most severe levels of suffering as a result of a mental health condition. True, there are conditions for which there is no prevention, though reducing the base-level of distress can enhance resilience and optimal functioning even under such circumstances. Further, many clients appear to find some benefit to checking in with a therapist after the worst of their symptoms have been resolved. Many clinicians frame this kind of intervention as "relapse prevention" or "maintenance therapy."Unfortunately, therapy or other related psychological interventions that are used as a preventive or maintenance of symptom remission are not typically covered by health insurance. This lack of coverage for preventive and maintenance services is not unique to psychotherapy. Health insurers rarely cover preventive treatments for providers who are not physicians, nurse-practitioners, or physician assistants. For example, health insurers also do not cover sessions with a dietitian/ nutritionist or physical therapist for preventive or maintenance purposes. I would,however, argue that they do cover maintenance of many physical health conditions and evensome mental health conditions, when care is provided by a physician, nurse practitioner, or physician assistant; however, these are primarily focused on prescriptive intervention. Paradoxically, scientific literature demonstrates questionable efficacy for the long-term treatment of depression and anxiety conditions with antidepressants. I have personally worked with clients who were prescribed antidepressant medications for decades, with such poor symptom-response that they sought psychotherapy to manage suicidal ideation. It is important to keep in mind that many health insurance companies are big businesses that work to balance reimbursement of patient services with stock-holder profit. If it isn't absolutely medically necessary, it isn't going to be covered-- even if it does contribute to your overall wellbeing and enjoyment of your life.
Diagnosis
In order to use your health insurance, you must meet the diagnostic criteria of an established mental health condition, as outlined in the Diagnostic and Statistical Manual of Mental Disorders(DSM-5) or International Classification of Diseases (ICD-10). That means that you will have amental health condition in your health record, which can (sadly) have implications for things like your career and life insurance. I will say that getting treatment is typically the better choice than stuffing things into some dark corner of your mind (because research shows that sort of behavior just doesn't work). While it is also possible to have a mental health provider evaluate you for the presence of the previous diagnosis in the future, should it interfere with work, that expense falls on you as it is not a medically necessary service. Early in my training in Counseling Psychology, philosophical discussions were had around the utility of a diagnosing a specific condition vs treating the symptoms of discomfort that a client was experiencing. This was back in the days when health insurers only covered a specific number of sessions and excluded pre-existing conditions from coverage, so most mental health providers didn't force themselves into the cookie-cutter medical model of mental health.Currently, if you arrive for therapy and you do not have symptoms that fit a DSM-5 or ICD-10 diagnosis, a therapist can still work with you, though your health insurance will not cover the sessions.
Record Privacy
It's important to know that when a health insurer is the payor source, they can request your session notes at any time during or after your treatment (and they do). Your health record has more privacy when you work with a therapist who is not associated with a larger medical facility and without using your insurance. There is no exchange of information with your insurance company for payment or audit purposes. When not using your health insurance for therapy, yourfile can still be subject to limits of confidentiality (e.g., subpoena, national security, CPS & APSreports, and danger to self or other), though these conditions are distinctively different than a health insurer's requests for your records.
Summary and Concluding Thoughts
Hopefully, you now have a better understanding of what the parameters are when using your health insurance to cover the cost of therapy. Your symptoms must be severe enough for a diagnosis, treatment must focus on the remission of those symptoms, session time and number are limited to the definitions of medical necessity set forth by your insurer, and your full record can be requested and read by your insurer. This information is not in any way meant to deter you from using your health insurance-- it is meant to help you fully understand how your mental health care may be affected and to help you better understand why your therapist may require shorter sessions, spread out your sessions, frequently discuss and measure your symptoms,and suggest ending therapy before you want to, even when you feel like therapy is helping you stay on track.
** DISCLAIMER: The information in this blog is informative only and is limited to the experience,knowledge and opinions of the author. The content should be read with caution and individuals are responsible for doing their own research and speaking with relevant professionals (e.g.,legal, mental health, medical, insurance plan, educator, etc.) before making any decisions based on the information read here. Use at your own risk. The information in this blog is not a substitute for consultation with relevant professionals (e.g., legal, mental health, medical,insurance plan, educator, etc.). The author, entity, and/or poster of this content is not responsible for its use.**
Griswold, B. (2020). Navigating the Insurance Maze (8th edition). Barbara Griswold, LMFT.https://theinsurancemaze.com/store/
American Psychological Association (2017). PTSD Clinical Practice Guideline. How Long Will It Take For Treatment To Work? Accessed 02/12/2023 from https://www.apa.org/ptsd-guideline/patients-and-families/length-treatment#:~:text=Recent%20research%20indicates%20that%20on,by%20self%2Dreported%20symptom%20measures.