Starting mental health care is hard enough without a surprise bill. This guide explains the common insurance terms in plain words. Your plan documents and your insurance company have the final word on what you owe.
Key terms
- Deductible: the amount you pay for covered care each year before your plan starts to pay.
- Copay: a fixed amount you pay for a covered visit, such as $20.
- Coinsurance: the percentage of the cost you pay after you meet your deductible, such as 20%.
- Out-of-pocket maximum: the most you pay for covered services in a plan year. After you reach it, your plan pays 100% of covered costs.
- Allowed amount: the price your plan agreed to pay for a service. Your deductible and coinsurance are based on it.
- In network: the clinician has a contract with your plan. Out-of-network care usually costs more, or may not be covered.
- Prior authorization: approval your plan may require before some care.
An example
These numbers are only an example, not your plan's real prices. Say the allowed amount for a visit is $100 and your coinsurance is 20%.
- Before you meet your deductible: you pay the full $100.
- After you meet your deductible: you pay 20%, or $20, and your plan pays the rest.
- After you reach your out-of-pocket maximum: you pay nothing more for covered care for the rest of the plan year.
Insurance or self-pay?
Early in the year, or with a high-deductible plan, you may pay the full allowed amount until you meet your deductible. In that case, compare your plan's estimate with our self-pay prices: $139 for the 60-minute first evaluation (regularly $179), and $75 for a 15-minute or $100 for a 30-minute follow-up (regularly $120). Self-pay visits usually do not count toward your deductible.
Insurance often makes more sense when your deductible is already met, your copay is low, or you expect many visits this year. If you have Medicare or TRICARE, contact us first, because those programs have their own rules.
How to check your cost before you book
- Find your plan's name on your insurance card.
- For commercial plans, open your provider's Headway profile from our insurance page to check participation and an estimated cost.
- Ask your insurance company: Is this provider in network? Have I met my deductible? What is my copay or coinsurance for outpatient mental health visits by video? Do I need prior authorization?
- Still unsure? Email us your plan name. Please do not include your member ID.
Read our guides to Medicare and TRICARE.
