Insurance coverage can be a great thing for families and individuals to have. It helps to offset the costs of many medical and mental health treatments. One downside to having insurance is that it sometimes does NOT cover certain services. Couple or family therapy may or may not be covered by insurance, and that is determined by a number of different factors.
Before we get into why couple therapy may sometimes NOT be covered by insurance, let me explain how couple therapy CAN be covered by insurance. Insurance companies determined the general requirements regarding what constitutes ‘medically necessary’ when identifying if a service can be reimbursed by your plan. The following criterion regulate what is deemed ‘medically necessary’:
A medical diagnosis is needed to bill insurance. Mental health professionals use DSM-5 codes to diagnose concerns that clients are treated for. Some common codes include, but not limited to, any of the following:
- F32.1 – Major Depressive Disorder, Moderate
- F41.1 – Generalized Anxiety Disorder
- F43.20 – Adjustment Disorder, Unspecified
- Z63.0 – Relationship Distress with Spouse or Intimate Partner
- Z63.5 – Disruption of Family by Separation or Divorce
- Z62.820 – Parent-Child Relational Problem
Insurance companies want to know that a treatment being used for the diagnosis is evidence based (i.e. backed up by research evidence) and will come to a reasonable and expected end. To ensure providers use evidence based interventions, we write a treatment plan which describes how we plan to help clients achieve relief from their symptoms. Sometimes the insurance company will ask us for a copy of the treatment plan or a copy of the progress notes to verify we are following the treatment plan. If this happens, we will let you know of this request and help you understand the potential implications of submitting those records.
Insurance companies require mental health providers to use the ICD-10 CPT codes to describe the services we provide to clients. The following are the most common CPT codes used at Aspen Grove Family Therapy:
- 90791 – Intake appointment
- 90832 – Individual Therapy, between 16 and 37 minutes.
- 90834 – Individual Therapy, between 38 and 53 minutes.
- 90837 – Individual Therapy, between 54 and 60 minutes.
- 90847 – Family Therapy with the Primary Patient Present (between 16 and 60 minutes).
- 90846 – Family Therapy with the Primary Patient not Present (between 16 and 60 minutes).
Your individual insurance plan that you pay your premium each month for or that you receive from your employer often will also determine whether or not your services may be covered. We generally have access to broad definitions of what your plan covers. It is your responsibility to know if your plan covers any particular service, diagnosis, or intervention.
When a counselor or therapist sits down with a couple, they have to determine whether what the couple is experiencing can be treated using couple or individual therapy. If it is determined that a medical diagnosis (i.e. depression, anxiety, sexual dysfunction, etc.) can be alleviated and improved using evidenced based couple or family therapy interventions, then insurance often covers the treatment. Sometimes even if the diagnosis and treatment are supported by research, some insurance plans do no cover the service of couple or family therapy. As a Systemic Family Therapist, I see most couple relationship problems as a dynamic between the two individuals. Each individual brings in their own mental and physical health concerns. Research has demonstrated that treatment as a family or couple is beneficial to each individual and their individual concerns. Therefore, we at Aspen Grove Family Therapy will make every attempt to make a diagnosis, treatment plan, and service match what the client family has covered in their plan. However, in those instances that these determinant’s of medical necessity do not align with a clients insurance plan, we are ethically and legally bound to charge our private pay rate for those services.
We will do everything in our power to allow you to use your insurance plan for services. Every provider at Aspen Grove Family Therapy utilizes evidence based interventions, which are generally accepted by insurance plans. It is your responsibility to verify that your diagnosis, and the service we need to bill, will be covered by your plan. If you are uncertain about this, please call our office and schedule a consultation call with your provider prior to the first appointment to see if they can help you navigate this question.