We all pay a great deal for health insurance, and we all want our insurance providers to cover the maximum amount of services that we are entitled to. However, it is important for those seeking couples therapy to understand what their insurance actually covers, and what it does not.
Will your insurance pay for marriage counseling?
The question is a good one, and I’ll walk you through how to find out, and how NOT to be stuck with a bill you didn’t anticipate. Will your insurance pay for marriage counseling? Probably not. And if they do, your therapist might not be allowed to provide treatment that is evidence-based or research-based in a session that is one hour-twenty minute sessions.
With very few exceptions, Health Insurance reimburses a therapist only for the diagnosis and treatment of mental illness. However, the good news is that tax programs may help you pay for your couples therapy, even if you are self-employed. These tax laws allow couples to use Pre-Tax Flexible Spending Medical Accounts (FSA’s) to pay these costs. Straightforward “marriage counseling” is usually not covered in HSA’s. FSA’s are usually more flexible in what they reimburse for. Treating sexual problems or sexual incompatibility is more likely to be covered. Ask your Accountant or Compensation and Benefits Administrator if you qualify for either program.
How do you find a good marriage counselor?
Avoiding Claw Backs
A large percentage of people who are seeking a therapist do so because they want help with their marriages.
Insurance companies, by and large, do not cover the cost of this type of treatment. They don’t have to. And they are increasingly clamping down on therapists who claim to practice couples therapy, while billing your insurance company as if they are treating one of you as an individual, not part of a couple.
Why should you care how your therapists bills the sessions?
The reason is simple: If your insurance provider finds this kind of insurance misuse, it might be months before they retroactively refuse to pay for sessions they inadvertently ALREADY paid for. That means they might pay the claim today, but demand payment from the therapist tomorrow. It is called a “claw back,” and it happens routinely, especially to large group practices, once yearly audits occur.
Health New England Engages in Clawbacks
In fact, it is happening right now in New England to about 50 psychotherapy practices. Health New England is one company. You will not hear anything about why your couples therapist has stopped accepting Health New England, because they have a “gag rule” that prevents your couples therapist from telling you the truth, but here it is:
HNE doesn’t PAY for couples therapy and never have. And now they’ve decided that they need additional revenues, so they sent a letter and told your couples therapist: “We’re holding back tens of thousands of dollars from you, Dr. therapists, because you’ve misused 90847. And billed us ‘incorrectly.'”
It was a game of:
“I’ll (the insurance company) ignore what you (the therapy agency) is doing, because our subscribers like couples therapy.
Wait, I’ve changed my mind…”
And there you are, the couple in a troubled marriage, receiving treatment, and your therapist simply stops seeing you. Or goes into limbo and doesn’t tell you why. Or see you for 1/2 the 90 minute session, and won’t even LET you pay for the other half out of pocket. Why? They can’t tell you why because of the gag rule they signed. And perhaps in 6 months, they go out of business…
Whether Your Insurance Pays or Not, You are Still Liable
For this reason, most therapists have clients sign a document indicating that if an insurance claim is denied, the client is still responsible for payment. You should check carefully ahead of time, to avoid what happened to John and Sheila (the story that follows) from happening to you.
What does a comprehensive Marriage Counseling Assessment cost? Learn more.
John and Sheila Go for Couples Counseling
Let’s follow along as one couple tried to get payment for couples counseling from their insurance company, and thought they had all of their bases covered:
Waiting to talk to a human being at the insurance company, John heard a recording that went something like this:
“A quote of benefits or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.”
John was too upset to sleep one night, after a big fight with his wife, so he read the member’s contract aka “his insurance policy,” from cover to cover. He read that they will pay only for what they consider to be “medically necessary.” This meaning that they have the right to withhold payment if it is considered outside the scope of the policy.
This is true even if they tell you, in a telephone call, that you are covered for that service.
Can John go to marriage counseling? Yes.
Will it be covered under his policy? The person on the other end of the telephone told him they cover couples therapy. He even got an authorization number. He’s all set to go, right?
Probably not, and here’s what happens:
Step One: Find an In-Network Provider
John found a therapist in his plan and he and his wife went to treatment. They have a $30 co-pay, which they paid at the time they were seen. They were seen for 45 minutes, which is what their insurance would reimburse.
The therapists, who is an “in-network provider,” then sent a bill to his insurance company for the balance. That claim includes information about
- Dates and Location of Service: When and where they were seen;
- Procedure Code: Whether John was seen alone, with his wife, or with other family members; and
- The Diagnostic Code (what mental illness the patient has).
# 1 and # 2 Above Will Not Stick You With A Bill. It’s All About #3 …Your Diagnosis
This is the most confusing part to most people. Your insurance will pay for both spouses being in the room (Procedural Code) and the clerk on the phone will say “Yes, we cover couples counseling,” because they see the Procedural Code “Couples/Family Therapy” on their computer screen. But a Procedural Code (Who’s in the Room) doesn’t kick out the claim. It is the Diagnostic Code that causes the claim to be rejected.
So Why Do They Cover Marriage and Family Therapy as a Procedure code only?
There are many good reasons why insurance would pay for a family member to be seen. Those with schizophrenia might be helped if their parents understood more about the disorder, and how to remain calm and not overly emotional, when psychotic episodes flare up. This is important psychoeducation.
So what about couples therapy?
A “Collateral” in Individual Work is Not “Couples Therapy”
If John had a severe depression, his therapist might ask his wife, Sheila, to join them for several sessions. She would be there as a “collateral,” and this would be fully covered. A collateral is usually a spouse, family member, or friend, who participates in therapy to assist the identified patient. The collateral is not considered to be a patient and is not the subject of the treatment, nor are they responsible for payment.*
Having a parent there for a child’s treatment, or a family member there to help another person with their mental disorder would be billed under the Procedural Code 90847: “Family psychotherapy, conjoint psychotherapy with the patient present.” John is the “patient.” His depression is the “Diagnosis.”
This is not couples therapy session.
The focus of treatment is NOT on their marriage.
Why does it matter if the focus is on the marriage, and not the individual? It’s the difference between remaining happily married, and staying married at all. Read more here.
If your therapist is planning to submit a bill for anything other than a V-code, one of you is the patient. It is important to know who that is, and what illness you are being treated for. And a treatment plan for that illness, as well.
Many clients were never told this fact, and were surprised to learn that they were given any mental illness diagnosis at all, when they just went for marriage counseling.
The Claims Department Process
Back to John and Sheila…The claim is probably submitted electronically, and the processors in the claims department of John’s insurance company reviewed the claim to insure accuracy in reporting and to determine if the treatment identified falls within the scope of the contract (“the insurance policy”).
The claim that their psychotherapist submits must accurately state the following (that was listed above):
- When and where they were seen (Date of Service/ Office Visit);
- Whether John was seen alone, with his wife, or with other family members (Procedural Code); and
- The diagnosis (what mental illness the patient has) (Diagnostic Code).
So because John and Sheila came in for help in managing their marriage, fights, or their sexual issues, the appropriate code is V61.01 Relationship Problems, or something similar.
When the processor at the insurance company reviewed this claim (or more likely their computer program does…), they send a letter stating that the claim will not be paid because it falls outside of the scope of the member’s contract. They do not consider John and Sheila’s marriage counseling to be a medical necessity.
Therefore John and Sheila owe the therapist for payment. And they have agreed to pay for their session if their insurance does not.
The Brake Job and The Dental “Eye Exam”
There are two stories that will help explain why your insurance company does not think the health of your marriage is any of their business:
Auto Insurance Coverage
The first one I lifted from Dan Stober (thank you Dan!). This is the short version. You can read the entire analogy at Dan Stober’s website.
I have coverage on my car and it costs a lot to insure that car every year. If I submit a claim for my brake job, they would reject the claim. They would argue that “routine maintenance” is not covered in the contract. There is no disputing that you need routine maintenance, and without it, you’ll be more likely to cause accidents (when the brakes failed,) but your auto coverage policy still won’t pay for it.
The second analogy is my own:
Dental Coverage for Eye Examinations
I am a couples therapist, and if I apply to an insurance panel to practice couples therapy, my application will, rightly so, be rejected. Why? Because Most Insurance Companies Don’t Cover Marriage Counseling. If that’s all I do, they don’t want me. There was a time I did other things, and I did accept insurance. But now, couples therapy is my only job.
Try to find a specialist in “Couples Counseling” in Your Insurance Provider Panels. You won’t find them.
Check the list of “specialties” in your Behavioral Healthcare Panel. You will see treatment for depression, childhood problems, ADHD, and all sorts of disorders. But you will see nobody listed as a specialist in “Marriage Counseling” or “Couples Therapy,” even if they claim to do marriage and family therapy. Why? Because Most Insurance Companies Don’t Cover Marriage Counseling.
Optometrists don’t apply to Dental Panels, even though both professions work on the face. They are still different skill sets.
Ask yourself these questions:
- If your Dentist told you he or she did dynamite Eye Exams, would you use them for the “Mouth and Eye Special”?
- What if you didn’t have insurance coverage for eye exams, but did have dental coverage. Would that sway you to use your dentist?
- Would you be convinced if your dentist had read several books about how to do Eye Exams, and 10% of their business was seeing people for eye exams. Would you go then?
- And would you be shocked if your dental insurance company rejected the “eye exam” claim from that dentist?
- If you did go, would you expect your dentist to submit the eye exam bill to insurance as a “root canal” in order to get paid?
Sounds silly, doesn’t it. Of course you wouldn’t.
And just as you would not expect your dentist to lie for you, neither should you expect your psychotherapist to, either.
- Would you be angry at that dentist for giving you a barely adequate eye exam, even if your dental insurance covered it completely?
Of course you would be angry.
Because you expect a professional to maintain integrity, and to practice within the confines of their expertise.
And you would not expect a professional to risk their license, in order to save you money.
As Dan Stober says:
Your health insurance is like that. The benefits may be limited to treatment that is considered a “medical necessity.” My health insurance will pay for my appendectomy, but not my face lift (or my marriage counseling).
Remember: You’ve Agreed to Pay If Your Insurance Doesn’t
As Dan says, you ought to make an informed decision about therapy, and not get stuck with a bill (maybe months later) for something that was never going to be paid by your insurance company anyway.
…even if the person on the phone at your insurance company told you it was covered.
Be a Savvy Consumer of Behavioral Health Benefits
Read your policy online and be familiar with what each of these terms mean:
In-network (or Network) Provider
And don’t take my word for it. Call your insurance company, and when you do, be smart and know what to ask.
“Do you pay for marriage counseling?” because they may say “Yes,” meaning “You both can be there in the same room.”
You now know that that’s called a Procedural Code, (the procedural code for couples or family work is 90847, and it pays for 45-minutes of treatment).
“Do you pay for the Diagnostic Codes V-61.1?” (You can see a list of all DSM-V/ V-codes here.)
(ICD-10 Codes and DSM-5 Code: V61.1 Counseling for marital and partner problems)
Make them look it up. Don’t settle for some general answer like “We pay for all the codes.”
Ask specifically for code V61.1.
If they say “Yes!” you are in like Flynn. You have a rare plan that covers Marriage Counseling. Be sure to ask how many sessions they will cover. For some, I have found it is as short as 3-4 sessions. For others, they will pay for up to 10 sessions before they expect another diagnosis to be given. This is unfortunate.
Having taught the DSM in a Marriage and Family Therapy program, I know the literature. V-codes are just as serious and the distress is just as great, than other codes in the DSM. However, this bias against the use of V-codes are almost universal. They are treated as somehow “less problematic” than other diagnostic categories. This is, again, unfortunate.
I’ve put language to look for you your policy at the end of this document as well.
If you check ahead, at least then you know whether your couples therapy sessions will be legitimately paid for, and you won’t be stuck with an unexpected bill in the future.
Have more questions about Insurance? Read this FAQ
Want to know how to find a skilled couples therapist? Read more here.
Is “bad marriage therapy” worse than “no marriage therapy?” Read what one expert in the field has to say here.
*unless they are legally responsible for the client. A parent, for example, is a collateral to children seen in therapy.
Exclusionary-type language in your policy might look like this:
“Mental health treatments for V-code conditions as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association which, according to the DSM, are not attributable to a mental health disorder or disease are excluded.
“Additional Information: The lack of a specific exclusion of a service does not imply that the service is covered.
“The following are examples of circumstances under which mental health treatments for a V-code condition are excluded (not an all inclusive list).
The problem is the focus of diagnosis or treatment and individual has no behavioral health condition (e.g., a Partner Relational Problem in which neither partner has symptoms that meet criteria for a behavioral health condition).
The individual has a behavioral health condition but it is unrelated to the presenting problem (e.g., a Partner Relational Problem in which one of the partners has an incidental behavioral health condition), and the problem – not the behavioral health condition – is the focus of diagnosis or treatment.”