Does Insurance Cover Couples Therapy?
Little Known Ways to Absolutely Guarantee to find out if it does (or is not)
I'll walk you through how one couple found out ahead of time and avoided owing money to a therapist.
Before starting couples therapy, know how to determine: Does insurance cover couples therapy?
Follow along as John and Sheila try to get reimbursed for couples therapy.
They thought they had all their bases covered, but realized only later what they needed to know:
Step One: Know the Lingo
In addition, be familiar with the following phrases:
Most health insurance companies limit treatment to conditions considered a “medical necessity.” Health insurance is a business designed to pay for necessary services, only. For example, they will pay for a deviated septum, but not a rhinoplasty (nose job)." They consider the first a medical necessity; the latter is not. Does Insurance Cover Couples Therapy? It will depend upon whether they pay for Z codes or not. A troubled marriage is a problem, but most insurance companies don't consider it their problem. A troubled marriage is not a "mental illness."
Simply put, a collateral is a family member or friend who comes into treatment to help the patient with a diagnosable mental disorder. The collateral can learn more about the condition, learning better ways to react to the patient's disordered behavior, and how to stay emotionally regulated when, for example, the loved one's disorder keeps him or her up at night, causes them extreme irritability, or in other ways impedes the successful functioning of the family.
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 under John's insurance. 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. John and Sheila would NOT be doing couples therapy, even if Sheila might learn to be more tolerant or helpful to John in his current condition.
Your insurance may covers "couples therapy" only if one of you is a "collateral." But while an important service, this isn't actually couples therapy.
Being considered a "collateral" means that one person is labeled as having the problem, while the other is not. The focus of treatment is then on that patient. This is not actually couples therapy, although it is appropriate and effective treatment.
Few of our clients want to be labeled "the problem" in couples therapy. In fact, often they come in pointing the finger at each other as the one who "needs help." Clinical labels, even if only used for reimbursement, are more destructive than helpful to productive couples therapy.
A Procedural Code (CPT)
A Procedural Terminology (CPT) codes, also known as service codes, are a universal system that identifies medical procedures. Each procedure is given its own unique five-digit code that identifies to health insurance companies what type of care was provided. In mental health, the procedural code will change depending upon whether one or more people are in the room while therapy is going on.
A Diagnostic Code
This is the most confusing part to most people. Your insurance will pay for both spouses being in the room (Procedural Code) and often 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. Whether or not your insurance cover couples therapy depends upon whether they cover z-codes.
The diagnostic code tells the insurance company what condition is being treated. When the condition is a troubled relationship, the correct diagnostic code is Z63.00. But unless you realize that the CPT only refers to how many people are in a room, and NOT what treatment is being provided, you can be misled.
So Why Do They Cover Marriage and Family Therapy as a Procedure code only?
Understanding The claims department process
Most of today's claims are submitted electronically, and the processors in the claims department review the claim to ensure accuracy in reporting and to determine if the treatment identified falls within the scope of the contract (“the insurance policy”). While the claim may have a procedural code outlining that two or more people were in the room, the diagnostic code informs the company whether the service is covered.
Step Two: Read your policy
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 means that they have the right to withhold payment if it is considered outside the scope of the policy.
He looked for language that sounded 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.”
This means that just because you are told over the phone that the marriage counseling service is covered by insurance, doesn't mean that it actually is.
John now knows he must be particularly careful about what he asks and verify that information by looking in his insurance materials.
John will look for exclusionary-type language in his policy that might look like this:
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.”
This language tells John that a "problem" is a "diagnosable mental disorder" and the "incidental behavioral health condition" is his troubled marriage. The first is covered. The second one is not.
Step Three: John calls his Insurance Company
John was smart and knew what to ask.
He didn't care what Procedural Codes his insurance would reimburse for. He now wanted only to know whether his insurance will reimburse for proper the Diagnostic Code for marriage counseling: Z-63.00.
Verbal authorization is no guarantee of coverage.
He knew this was true even if the clerk told him that "all codes are covered" and gave him an authorization number.
He pressed on to ask her to "look up this particular code: Z-63.00."
“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 50-minutes of treatment).
Can John go to Marriage Counseling?
Will it be Insurance Cover Couples Therapy 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?
If he took their word for it, here is how it would go:
John would find a therapist in his plan and he and his wife would set up an appointment. They would pay a $30 co-pay at the time they were seen. They would be seen for 50- minutes, which is what their insurance would reimburse.
The therapists, who would be an “in-network provider,” would then send a bill to his insurance company for the balance. That "claim" would include information about:
- Dates and Location of Service: When and where they were seen;
- Procedural Code: Whether John was seen alone, with his wife, or with other family members; and
- The Diagnostic Code: (what mental illness the patient has).
John wanted a skilled couples therapist. He did not want to carry a mental health diagnosis, for several reasons including his need for a security clearance, his license to carry a firearm (requiring FBI clearance. He learned a Z code doesn't have to be reported), and other related issues. He wanted the diagnostic code to be listed as "Z63.00 Relationships Problem."
It would then be submitted to insurance and then rejected.
But armed with his current knowledge after reading his contract and speaking to his insurance company, he realized that they would only reimburse treatment if one of them was given a mental health diagnosis, and they would only be seen for 50-minutes.
From his previous research, John knew that this was inadequate time for effective couples therapy.
So, what about couples therapy?
In his persistence, he learned that his insurance policy would not cover any diagnosis with a Z-codes.
Now he knows.
About Couples Therapy
Effective couples therapy is a specialty field that requires not only post-graduate training, but also supervised experience. Research has demonstrated that longer sessions are more productive than 50-minutes.
Couples Therapy Inc. International - Minneapolis office.
Does Insurance Cover Couples Therapy? No?
Then use insurance benefits to resolve other mental health problems if Z-codes are not reimbursable (couples therapy isn't covered by insurance.)
Seek out skilled individual therapists who are trained to do exactly that.
Here are the most common mental health diagnoses used today:
What Makes Us Different
Couples Therapy Inc. is an international organization offering science-based couples therapists across the USA who are devoted to effective, intensive couples therapy. All of our therapists have advanced training in the famous "Gottman Method" of couples therapy and most have training in Emotionally Focused Couples Therapy, or other clinically validated methods.
Our intensive weekend and mid-week therapy offer couples the opportunity to get away to work on their relationship or work online to get the jump-start they need for better more intimate relating.
Specialized training in science-based couples therapy. Supervised by those who have experience in working with couples. The most well-known evidence-based therapy includes The Gottman Method, Emotionally-focused couples therapy, and integrative behavioral couples therapy.
Our intensive couples therapy is therapy starts with a unique only assessment instrument called: "The BIG BIG Book." We then conduct a thorough Gottman assessment and provide you specific feedback. Following this, our work is directed by our clinical findings and your needs.
Many of our couples therapists have 20-30 years' experience in helping troubled relationships. We have certified Gottman Method Couples Therapists, and trainers who train others in the Gottman Method, as well as those who are highly trained in sex therapy.
Headquarters of Couples Therapy Inc.
125 Guest Street, Boston Landing, MA, 02135, USA
Call Toll Free: 844-926-8753International Callers: +1 212-519-7523
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