Updated April 13, 2021
Marital or relationship problems severely impact the health and wellbeing of the individual and the family. We know from clinical research that relationship distress worsens common ailments such as depression and anxiety. And while treatment for marital distress has had a legitimate insurance diagnostic code for decades, and in its most recent form since 2016, (Z63.0), few clinicians use it. We'll answer why and many other questions as we explore: "Does Health Insurance Cover Marriage Counseling?"
When does health insurance cover marriage counseling?
While most standard plans won't cover what we normally think of as "marriage counseling," here are four totally legit ways to get the help you need:
1. Employee-Assistance Programs
Your employer’s Employee Assistance Program (EAP) may be the first place to check whether you can get marriage counseling covered as a benefit. Many EAP's cover a broader range of health care benefits than insurance plans alone. An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
Best of all? While some EAP programs are kept in-house, others are contracted to outside mental health providers, so you may find yourself going into a private office, and not a company HR Department.
2. Collateral coverage
Simply put, a collateral is a helper. Parents go to "play therapy" to get guidance as to how to best handle the child, but it is billed under the child's diagnosis. The parent is only there as a "helper" or "interested party."
But if your partner is suffering from a severe disorder that is impacting your relationship, you can become a helper who learns more about the illness and how you can respond effectively to this disorder. It's an effective use of your insurance dollars, whether or not you are covered under your partner's health insurance plan. These sessions can be schedule with the both of you, or privately with you alone, and you'll still be covered under the patient's insurance.
How collateral coverage is different than 'marriage counseling'
A collateral spouse is NOT the patient and is not the focus of treatment. Neither are your marital troubles as a stand-alone issue. Further, the collateral is under no obligation to pay for this treatment. But can it improve your marriage? Sure, it can.
If your husband has alcoholism, or your wife was hospitalized for depression, you may be asked to participate in treatment for a wide variety of reasons:
- to gain vital knowledge of the mental health condition
- to establish appropriate boundaries
- to learn how to respond to emotional outbursts, chronic irritability or delusions.
But in every one of these cases, the treatment is focused on your partner and how you can assist them in healing.
3. Find university clinics or public health clinics that work under grants
There are many excellent university and training clinics that offer free or low-cost marriage counseling. Many have been given block grants or grants from the National Institute of Mental Health to support the community and have greater flexibility in providing couples with longer and more frequent sessions than private practice providers can.
Just because these services are low cost or free, doesn't mean you have to accept whatever you're offered. Make sure that the therapist you see is fully trained as a couples therapist (not just has a degree in Marriage and Family Therapy) and has received or is currently receiving supervision from an experienced couples therapist.
These research departments may be conducting ongoing studies as to how to better help spouses where one or both partners are suffering from serious mental disorders such as mood disorders (depression, bipolar disorder, dysthymic disorder), thought disorders (such as schizophrenia or schizoid disorder), or anxiety disorders (such as generalized anxiety, agoraphobia, or social phobias.)
Taking part in these types of services not only provides you with the most innovative treatment available, but also helps further the entire field of mental health.
The University of Minnesota, for example was instrumental in developing Discernment Counseling with faculty member Dr. Bill Doherty. Those lucky couples who sought low or no cost treatment received innovative services from an internationally recognized expert.
Contact your local university or mental health clinic and ask if they have ongoing research projects or train graduate interns in couples therapy. While an intern may have less years of clinical experience, they may also have had the most up-to-date clinical training. They also are supervised by more senior, experienced, staff members.
4. Receive treatment for a sexual dysfunction when covered by your plan.
While it is possible to receive individual treatment for sexual health problems, conjoint treatment (the two of you seen together) is a perfectly legitimate way to have your couples therapy covered. Be certain that your therapist has the qualifications to practice as a sex therapist. It may be necessary and preferable for couples therapy to be an integral part of the clinical work done on helping one or both of you with your sexual problems. But be sure treatment of sexual disordered is covered by your plan. Many do even though it's not a Z-code.
Three unlikely ways health insurance covers marriage counseling:
1. ACA Health Insurance
While the Affordable Care Act (ACA) considers mental health to be an “essential benefit” for individuals, marriage counseling isn't covered because it is not a treatment for mental illness. Collateral coverage is often the exception.
Cobra is an extension of your employer coverage. If this coverage included payments for Z-codes (Z-63.00: relationship problems), you would continue to receive this reimbursement. If it didn't cover Z-codes while you were working, it's not likely to do so now. Read your policy carefully.
Medicare Part B covers collateral family counseling. In other words, if you are a "collateral" there to offer support, gain knowledge about your spouse's condition (such as dementia), and how to adapt to it more effectively, your spouse's Medicare coverage will kick in.
But this is no small thing. The slow and insidious onset of dementia disorders like Alzheimer's Disease requires couples to work together early in the disease progression. It allows both to plan for the inevitable decline of cognitive and self-care function, so your spouse isn't left on their own. Also, don't forsake your own need for individual therapy during this time. It's an appropriate use of health insurance funds.
Why does health insurance cover marriage counseling?
What is a Z-code?
Z codes are a special group of codes used for reporting issues that impact health status (like a troubled marriage) but are not considered a mental illness.
IF HEALTH INSURANCE COVERS MARRIAGE COUNSELING, IT WILL DO SO because all Z-CODEs are covered by your health insurance plan.
A Z-code accurately describes marriage counseling but, few providers use it when seeking reimbursement.
They’d rather not risk wasting their time and the client’s time submitting a claim when it is most likely to get rejected by your insurance company.
As Dan Stober says:
"Your health insurance is like that. The benefits may be limited to treatment that are considered a “medical necessity.” My health insurance will pay for my appendectomy, but not my face lift (or my marriage counseling)."
Medicare does not cover marriage and family therapists (MFT's) unless a clinical facility, hospital, or other Medicare eligible agencies employs them.
MOST INSURANCE PLANS COVER WHAT THEY CONSIDER TO BE "MEDICALLY NECESSARY." Z-codes often fall outside this definition in most plans.
Does health Insurance cover marriage counseling?
Yes, but doing it fraudulently is asking for trouble.
There is one common way people get their health insurance company to pay for marriage counseling: fraud. Your therapist labels one or both of you as having a mental health disorder that is covered by your insurance, and then proceeds to do marriage counseling. This fraud can use one person's coverage, or alternate using both.
Sometimes therapists will agree to see you for a longer-evidence-based length treatment (80-90 minutes) combining each session into one longer one. You are each given a diagnosis if this is the case. This diagnosis is supposed to be the focus of treatment, but the therapist will agree, instead, to practice couples therapy to help your troubled relationship.
This practice is both a federal crime and unethical, but it continues to be practiced.
What is a diagnosis for?
A diagnosis is designed to guides treatment. Medically, an ulcer has a different diagnostic code than an appendectomy, and for good reason: both require a different approach to cure.
Almost all clinical psychiatric diagnoses have established science-based approaches that are used when proven to be effective with a specific diagnosis. An approach to a thought disorder will be handled differently than an affect disorder.
What's more, a diagnosis becomes part of one's medical record to inform and guide all future healthcare decisions, mental health related or not.
Misdiagnosis for health insurance reimbursement of marriage counseling
Some therapy reimbursement sites and website articles actually recommend that clients or therapists use diagnostic criterion such as "adjustment disorder" or "dysthymic disorder" instead of the proper Z-code to secure insurance payment.
They'll argue that insurance reimbursement is just a game, anyway, and "everybody's doing it, so it's okay."
And, as we've learned from our clients, many have neglected to inform the client that they've been given a diagnosis never mind discuss what impact their unilateral decision might have.
Diagnosis shouldn't be a "game" played by reputable therapist, nor should it be for you, the couple.
Misdiagnosis can have grave consequences. Don't accept the answer "I accept your insurance." Ask if you''ll be given a diagnosis and ask what that label will be. And be sure to talk to them about the consequences of receiving a diagnostic label so.
Use a "family session" code
Other advice suggests asking your therapist to bill your treatment as a "family session" and promises that this will be a less expensive or more cost-effective way to get your marriage counseling reimbursed.
Whoever proposes this solution has no idea how insurance billing works. All mental health services involving more than two people in the room are billed as either Procedure Code 90846 (Family psychotherapy without the patient present)- 50 minutes) or 90847 Family psychotherapy conjoint psychotherapy with patient present - 50 minutes.)
And each of these procedural codes are used with "collateral" sessions as described above. "Procedural code" are not diagnostic codes and will NOT allow the sessions to be reimbursed on their own. All procedural codes are combined with DIAGNOSTIC codes and both are essential to determine whether your policy will be covered by insurance.
While the Procedural Code describes who is in the room, the Diagnostic Code informs what problems are being addressed.
It is remarkable that after decades of clinical practice, many therapists remain confused about the difference between Procedural Codes and Diagnostic codes.
I've provided a detailed explanation on how to find out if your particular insurance plan will pay for Z-codes. Follow the three steps offered in this helpful article to be confident what to ask, before calling around to find a provider.
When does health insurance coverage for marriage counseling become more trouble than it is worth? Five big reasons:
DIAGNOSIS USING ANYTHING BUT A Z-CODE HAS LIFE-IMPACTING RAMIFICATIONS.
There are five big reasons why accepting a mental illness diagnosis in order to have your marriage counseling covered by your health insurance. The first two address ethics and your wallet; this practice is insurance fraud and the therapist might have their funds "clawed back" and drop your insurance company (and you in the process). The other three are more personal. Diagnosis information goes onto your permanent health record potentially impacting; employment, firearms ownership, and security clearances as well as military service. Z-codes used to cover marriage counseling do not have this impact on your health records.
I. Insurance fraud
Lying to get benefits you don’t deserve is INSURANCE FRAUD. Misrepresenting non–covered treatments as a medical necessity is also blatantly illegal. False or misleading information deliberately provided to a health insurance company to procure unauthorized benefits to the policy holder‚ or to the therapist providing services is a federal crime.
Even if your provider of health services, commits the fraud, but if you knowingly participate, you are culpable.
Most therapist require you to sign an agreement stating that you are responsible for payment of their full fee (often higher than they accept from insurance companies) if your insurance company does not pay for coverage.
Insurance companies are well aware that 40% of people calling therapy offices are looking for help with a troubled relationship. They also know that including Z-codes as part of their standard coverage would drive up insurance premiums and costs astronomically. They are also aware of fraudulent efforts to treat couples while claiming it is actually treatment for a diagnosable mental illness. They are increasingly clamping down on therapists who practice this way.
In fact, it happened a few years ago in New England to about 50 psychotherapy practices. Health New England (HNE) was one company. You will not hear anything about why these therapists have suddenly stopped accepting Health New England, because therapists have a “gag rule” that prevents your therapist from telling you the truth, but here it is:
HNE doesn’t PAY for couples therapy and never has. They sent a letter out to hundreds of therapists telling them: “We’re holding back tens of thousands of dollars from you, Dr. therapists, because you’ve billed us incorrectly."
It's all done effortlessly and electronically after comparing payment records.
Future funds are then withheld. These therapists are now forced to either "see you for free" or cancel their contract, (and your treatment) at the same time. And they may ask you to pay out of pocket. They could also keep the insurance and ask you to pay for past treatment they are no longer (technically) being reimbursed for. The kicker is that the gag rules prevent them from even telling you why they can no longer accept your insurance or the other impossible decisions they must make.
III. Employment-related issues
While insurance records are required to be kept private, an employer can request access to an incoming employee's mental health records, as long as they make the same request of all incoming employees.
IV. Firearms Licenses
The FBI’s gun-purchase background check systems include mental health records in their National Instant Criminal Background Check System (NICS).
V. Military and Security Clearance
Also, while treatment using straight Z-code (Z-63.0) for marital counseling do not flag NICS security clearance question 21, other diagnostic codes, including other Z-codes, can and do flag this question and must be answered in the affirmative (for example, treatment for domestic violence (counseling for spousal or partner abuse problems (Z69.1))
Highly regarded and sought-after plastic surgeons do not disguise what they do to get insurance reimbursement. They know that some insurance plans will cover many types of plastic surgeries, while most restrict what can and can't be done and under what circumstance.
Botox, for example, isn't covered by health insurance for cosmetic use, but is fully covered by both commercial plans and Medicare for migraine treatment. Otherwise, it costs between $400 to $700 per treatment.
Is Botox covered by health insurance?
If you questioned enough plastic surgeons, you may find one or two who would be willing to commit insurance fraud to cover your cosmetic Botox injections and say they were being used for treatment of migraines.
Is this ethical? No. Is it insurance fraud? Yes, it is.
Might it be possible to find someone who will commit this type of fraud? Possibly.
But is the ethics of this practice in debate? Certainly not.
You expect a professional to maintain integrity, and to practice within the bounds of their area of expertise. You also expect them to maintain this integrity in every aspect of their professional lives and not violate ethical guidelines to be "nice" or "helpful."
How often does health insurance cover marriage counseling?
We run a worldwide company exclusively seeing couples. And we've only rarely seen a client's insurance fully or even partially cover their marriage counseling services. The plans that do are usually C-level executive health insurance plans. These are rare and expensive "Cadillac plans," and even most of these limits the treatment received to no more than 10 sessions before expecting a psychiatric disorder to be given.
Negotiating executive contracts with coverage for Z-codes
If you are a C-level executive, it may be wise to negotiate an employment contract that includes Z-codes in your health care coverage to be in parity with all other types of diagnostic codes used to provide mental health services.
Why you may prefer to pay for marriage counseling out of your own pocket.
Focus on skill, not just cost, just as you would any specialist
Finding the most advanced and skilled couples therapist you can afford should be your top priority when searching for a couples therapist. Your wellbeing and that of your family may rest on the professional's clinical knowledge, training in couples therapy, and experience helping couples just like you.
Compare costs to a divorce attorney's retainer
The cost you pay for a good couples therapist should be compared not to what you'd pay if you used your insurance. It should be compared against the cost of hiring a good divorce attorney, as well as financing separate homes and separate lifestyles. However, while the couples therapist job is to keep you together, the divorce attorney's job is to separate you for good. The choice is yours.
Should most insurance plans cover marriage counseling?
It's a question that is seldom debated.
Should car insurance be required to cover brake jobs? Aren't brakes necessary to have a well-run car and avoid accidents?
Covering brake jobs would be great, but it would also increase the cost of car insurance premiums.
The same is true if standard health insurance plans covered marriage counseling.
As a society, we choose which services we believe are essential for our health and which ones are "experimental" or "optional. Whether you agree with it or not, most insurance companies today still consider marriage counseling "a problem, just not our problem," with regards to coverage.
A note to our colleagues
Therapists who attempt to "help" clients to get marriage counseling, by providing a reimbursable diagnosis on their insurance paperwork, are often well-intentioned.
But these actions may be doing more harm than truly benefiting your client or the public.
Many of our current clients were surprised to learn that they were unwittingly given a psychiatric diagnosis when they went for marriage counseling previously. They still have no idea what diagnosis that was. They also complain to us about the marriage counseling being ineffective. This is wrong on both counts.
First Do No Harm
Avoid creating iatrogenic marital strife
Clients who seek out couples therapy often fight about who is the "patient" (or the one 'with the problem...') and who is the "collateral" (or the passive, guiltless observer). This battle is made worse by labeling one or both with a gratuitous psychiatric diagnosis. While you may recommend individual therapy as an adjunctive treatment, marriage counseling (as opposed to collateral treatment) is focused on healing your client's marriage, not either one of them as individuals.
Casually diagnosing a client tells the couple that "he/she is the problem," no matter how innocuous you consider the label to be. It also weaponizes the spouse. "Adjustment Disorders" become "You just can't handle everyday life!"
Diagnostic psychiatric labels are serious business
Having a diagnostic "label," even a fraudulent one on your medical records, has important ramifications to your client's future life. While you, yourself may be totally comfortable having such a psychiatric diagnosis as part of your health history and want to normalize the presence of mental health problems, don't assume your clients agree with you. Many emotionally adaptive couples want help with a troubled marriage, and want insurance help to pay for it, but don't recognize the full implications this desire carries. As an ethical professional, your job is to present an unbiased and knowledgeable perspective, including all common ramifications.
Insurance reimburses typically for 50-minutes. Conjoint sessions require longer sessions than this.
Accepting these health insurance reimbursements require you to offer shorter 50-minute sessions, or risk that longer time periods you submit will be rejected. This makes sense. While few collateral sessions can justify 75–90-minute sessions, this timeframe is typical for couples therapy.
The ethical imperative to be well trained for any specialized service you provide
It is broadly accepted by all mental health professions that offering services when you have no specialized training is an ethical violation. Treating couples is one such specialty. Please stop seeing couples until you get adequate advanced training and good supervision.
We know that you were selected for inclusion by insurance panels because of your background as a generalist. You are most likely skilled to treat a wide variety of diagnosable mental disorders. This makes you a valuable clinical member of your community.
"Marriage counseling" however, is one specialty insurance companies haven't hired you to do. MFT's, who do amazing work helping a child or adult with a mental disorder within a family context, take only a single overview course in an MFT graduate school in how to help couples. And even these MFT's are not paid directly by insurance companies to work as couples therapists.
Trying to fit couples therapy into an insurance model is like pushing a round peg into a square hole. The approach is different, the skill set is different, and the time needed to perform the service is different. We've found when hiring our clinicians that couples therapy is as much a calling as any other specialized service in mental health. If you have that calling, trust yourself and get the training you need to work in evidence-based sessions free of health insurance panel restrictions.
If you don't, seek out trusted colleagues who will be glad to refer individual clients to you, while treating your couples effectively.
Gratuitous Diagnosis is a federal crime
If you accept insurance reimbursement, you have signed a legally-binding contract. Know if your insurance panel offerings include Z-codes, and if not, don't seek out a diagnosis to tag a client with for reimbursement sake alone.
Defrauding insurance companies is a federal crime. Providing proper diagnosis to guide treatment is a professional ethical requirement. This point has been addressed in every mental health discipline and by every professional organization:
Diagnose properly, carefully, or not at all. Delivering diagnoses to simply receive insurance reimbursement is a legal and ethical violation. Don't do it.
We, like you, believe that everyone would benefit from obtaining effective, skilled couples therapy. We're also sure that you know that doing so would elevate insurance premiums, at least initially.
If 40% of the public are seeking out relationship help, and insurance companies begin to reimburse therapists for Z-codes, will premiums skyrocket?
Will overall healthcare costs plummet?
We, like you, believe they would.
But these are political questions that will only be answered in the public arena.
But one thing is clear:
If you practice marriage counseling as a therapist, please do not submit a bill for anything other than a Z-code.* And work politically to change the insurance laws if you believe that health insurance should, in fact cover marriage counseling and all Z-codes on parity with other mental health diagnoses.
- What if I have a diagnosis already?
- What if one is discovered?
- Should insurance pay?
What if I have a diagnosis already?
Many people do not want to be labeled with any sort of mental disorder because they are concerned about the impact these labels will have on other aspects of their lives. But even those who have such diagnostic labels often do not want their diagnosis to be the focus of their couples treatment.
Sometimes their spouses have blamed them unfairly, for years, as being “the problem” in the marriage. While prior bouts of mental illness can sometimes be an issue in marriage, this isn’t always the case. Most of us seeking couples therapy do not want to be considered “the problem.” We want to be considered an equal participant, a sane person, who should be respected and listened to, not labeled the “sick one” (however benevolent the intentions might be) who "needs help."
What if I actually have a mental illness that is discovered?
Sometimes a spouse will have an undiagnosed mental disorder. A thorough evaluation will determine this. If so, you should be referred to a skilled practitioner who will provide you with appropriate treatment. You should not have the same individual and couples therapist. It is perfectly appropriate to find an health insurance provider on your panel and billed for these servcies. Effective treatment of mental disorders is appropriate and often very helpful to the couples therapy.
Should insurance companies pay for Couples Therapy?
I guess the answer to that depends on your politics. If 40% of people looking for help are looking for couples therapy, that is a lot of payouts, and that means insurance premiums may rise.
Dr. K served on the Executive Board of the Massachusetts Chapter of the American Association for Marriage and Family Therapists for three terms. Our mission was to explore how to provide couples counseling to everyone. An argument can be made that functioning, healthy families reduces overall medical costs. It's an argument I agree with.
But we believe we are a long way off from seeing that goal become a reality. Much as we all might wish it were so. But while it is short-sighted for insurance companies to refuse to reimburse Z-code 63.00 and all Z-codes, that is currently the situation. Two wrongs to not make a right.
* we have made clear in this article that legitimate collateral couples or family counseling is an important and essential addition to individual psychotherapy. We further do not wish to discourage researchers or serious clinicians who are thoughtfully applying interventions to a conjoint setting. Such efforts have included partner-assisted agoraphobia, modest research support for conjoint treatment for depression, conjoint treatment for personality disorders, (no matter how nascent) and family interventions working with thought disordered clients or drug addiction. These services are fully legitimate uses of collateral treatment and we look forward to continued research to perfect such conjoint services.
Our beef is only with clinicians who "find the diagnosis" to "justify the payment," with no clear demarcation of the role of conjoint services for individual diagnosis, no clear patient education, and, if couples therapy is called for, no advanced training or systematic approach to helping troubled relationships.