The common belief is that couples counseling is covered by health insurance, as our relationships play a significant part in our well-being and health. When there are problems in your relationship, it is wise to see a professional who can help you heal. Technically, however, health insurance does not cover couples counseling.
Behavioral health coverage is an included part of the Affordable Care Act (ACA) and is considered an “essential benefit” for individuals. Marriage or couples counseling is not considered a treatment for a mental health illness; it is not a covered diagnosis, nor is it considered a “medical necessity,” which requires health services to treat a disease, injury, condition, or illness.
My insurance rep said it covers marriage counseling
When you call your insurance and ask, “Will my plan cover marriage counseling,” the usual answer is “yes.” However, they seldom tell you the rest of the story. Insurance will cover couples counseling if the cardholder has been diagnosed with a mental illness or disorder and couples counseling is part of the treatment plan to treat the disorder. Some insurance plans also limit how many sessions are allowed to address the specific disorder and what kind of therapy is used.
For example, a husband that has been diagnosed with clinical depression is seeing a therapist to address the symptoms. In the course of treatment, it is decided to bring in his wife for joint sessions; they learn how to manage the depression together. Part of the session helps them improve their relationship (couples counseling), improving the husband’s outcome. The therapist will then provide the appropriate codes (F32.9 Depression & Z630 Relationship w/spouse) to the insurance company for reimbursement.
Most insurance plans will only cover relationship counseling if it is tied to another mental health disorder. Insurance will say they cover couples counseling because they cover the procedure code 90847 (Family/couples therapy); however, the diagnosis code must also be covered. When you call your insurance, you need to be very specific that you are looking only at couples counseling with diagnosis code Z630. There is a difference in procedure codes and diagnosis codes; in this case, the diagnosis code needs to be approved by insurance. A clinician must include a “payable” diagnosis code to insurance along with the Z630 code. Some high-end plans will cover relationship issues alone; however, most do not.
Potential problems of using insurance for couples counseling
The first potential problem could be that the insurance refuses to pay. This is when the therapist submits the claim to the insurance. The insurance then rejects the claim and does not pay. Their refusal can be anything from “you paid your insurance premium late,” “the claim had a typo,” to they “believe that therapy was not a necessity.” The therapist will then go back to you to make payment for services. This process can often take months, although most insurance companies today pay or refuse within four months of receiving the bill.
The second issue that could come up is called a Clawback; this is when the insurance pays the therapist for services and then changes their mind and wants the therapist to refund what they paid. This usually occurs when the insurance has an audit, and the auditor decides services (like couples counseling) weren’t a “medical necessity” according to your plan. The therapist is then forced to pay the insurance company back. The therapist then contacts you for payment, which can be years after you received services. A few states only allow insurance companies a year to do this audit and chargeback process.
The third and, in my view, the most alarming problem is that of confidentiality. Whenever you use a third-party payer like insurance, you wave your right to privacy regardless of HIPPA. This means that the insurance company (who employ thousands of people with access to your records) and anyone who pays for your insurance (employers) can review your diagnosis, dates you saw a therapist, payments made, etc. The insurance company may also audit your therapy records and ask for therapist notes and all records of the services provided. With this information in your medical records, it may affect you in the future if you desire to: get life insurance, work in the financial sector, handle firearms regularly, work high-security jobs, or get employment where you need to make critical decisions. If confidentiality and privacy are essential, insurance may not be the best option.
Options to insurance
There are two main options to paying for couples counseling without using insurance. The first one is to use your employer’s EAP (Employee Assistance Program). Most large employers offer these services. They usually offer 2-8 free sessions to the employee with a therapist in the EAP network. The employer contracts with a third party to provide services. Confidentiality is preserved, and your employer will never know why or that you even used the service unless you tell them.
The second option is to pay cash or use a credit card. This method offers you complete confidentiality and more options in choosing a therapist. It also allows the therapist flexibility to select a therapy that is best for you rather than what the insurance will allow.
Using insurance for marriage counseling has its drawbacks and most likely will not pay unless you have another mental health issue. If it does pay, be prepared to still pay cash if the insurance changes their mind months or years down the road. Many therapists are getting away from accepting insurance in part due to the complexity and added costs involved.
Your relationships can affect all areas of your life in both positive and negative ways. It can affect your work performance and your physical health. Getting help from a qualified licensed therapist can make a huge difference in your life. Marriage counseling is an investment that can save time, money, and pain. ©
Marriage / Couples Counseling
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