Smart Ways to Use Insurance with an Out-of-Network Practice

At Maplewood Counseling, we provide inclusive care for people of all races, cultures, and backgrounds, including interfaith, interracial, BIPOC, LGBTQIA+, and blended families. Our therapists bring lived experiences and specialized training to create a safe, affirming space for all.

Smart Ways to Use Insurance with an Out-of-Network Practice

Investing in your mental health or relationship is one of the most important decisions you can make. When you seek specialized care, you want a therapist who is the right fit for your unique needs, not just someone who happens to be listed in your insurance company’s directory. At Maplewood Counseling, we are an Out-of-Network (OON) practice. This means we can provide you with a higher level of personalized, expert care without the restrictions often imposed by insurance companies.

Navigating insurance can feel complicated, but using your OON benefits is often more straightforward than you might think. Many clients successfully receive partial reimbursement for their sessions, making specialized therapy an affordable investment. This guide will walk you through how to understand your benefits, communicate with your insurance provider, and use tax-advantaged accounts to make your mental health journey more manageable.

Understanding Out-of-Network (OON) Benefits

What does it mean to be an “Out-of-Network” practice? It simply means that while we don’t have a direct contract with your insurance company, your plan may still cover a significant portion of your therapy costs. Choosing an OON provider gives you the freedom to select a therapist based on their expertise, approach, and connection with you, which is the biggest factor in successful therapy.

The primary benefits of choosing an OON provider include:

• Greater Confidentiality: Your diagnosis and treatment details are not shared with your insurance company unless you choose to submit for reimbursement.
• More Flexibility: We can offer longer, more intensive sessions tailored to your needs, without insurance-imposed limits on session length or frequency.
• Access to Specialists: You gain access to our team’s specialized training in couples therapy, family dynamics, and individual counseling that may not be available from in-network providers.
• No Treatment Delays: You can start therapy right away without waiting for insurance pre-authorizations.

Many PPO and POS insurance plans offer OON benefits. You pay for your sessions at the time of service, and we provide you with a detailed receipt, known as a “superbill,” which you can submit to your insurance company for reimbursement.

How to Estimate Your Reimbursement

Before you begin, it’s helpful to understand what your insurance plan will cover. The amount you get back depends on your specific plan’s OON deductible and reimbursement rate.

1. Find Your OON Deductible: This is the amount you must pay out-of-pocket before your insurance company starts to reimburse you.
2. Determine Your Coinsurance/Reimbursement Rate: Once you meet your deductible, your insurance will cover a percentage of the “allowable amount” for each session. This is often between 60% and 80%.
3. Know Your “Allowable Amount”: This is a key detail. It’s the maximum fee your insurance company considers reasonable for a specific service (e.g., a 50-minute therapy session). This amount may be lower than our actual session fee.

Reimbursement Estimator Example

Let’s walk through a simple calculation to see how this works.

• Your Session Fee: $200
• Your Insurance Plan’s Allowable Amount: $150
• Your OON Deductible: $500 (Let’s assume you’ve already met it.)
• Your Reimbursement Rate: 70%

Calculation:
Your insurance will reimburse 70% of their $150 allowable amount.
$150 (Allowable Amount) x 0.70 (Reimbursement Rate) = $105

In this example, your insurance company would send you a check for $105. Your final out-of-pocket cost for the $200 session would be $95.

We recommend calling your insurance provider directly for the most accurate information.

Scripts for Calling Your Insurance Provider

Calling your insurance company can feel daunting. Use the script below to guide your conversation and ensure you get all the information you need. Before you call, have your insurance card ready.

What to Say When You Call:
“Hello, I’m calling to verify my out-of-network benefits for outpatient mental health services.”

Your insurance representative will likely ask for some information. Be prepared to provide the following CPT (Current Procedural Terminology) codes for the services you plan to receive:

• Individual Therapy: 90834 (45-50 minutes) or 90837 (60+ minutes)
• Couples/Family Therapy: 90847

Questions to Ask Your Insurance Representative

Use this checklist to gather all the necessary details during your call.

Download or Copy These Questions:

Key Questions for My Insurance Company:

1. Benefits Confirmation:
2. • “Do I have out-of-network benefits for outpatient mental health services provided via telehealth and in-person?”
2. Deductible Information:
3. • “What is my annual out-of-network deductible for an individual and for my family?”
   • “How much of my out-of-network deductible has been met so far this year?”
   • “When does my deductible reset?”
3. Reimbursement Details:
4. • “Once my deductible is met, what percentage of the session fee will you reimburse? Is this based on the billed amount or an ‘allowable’ amount?”
   • “What is the ‘allowable’ (or ‘usual and customary’) amount for the following CPT codes: 90834, 90837, and 90847?”
4. Submission Process:
5. • “How do I submit my superbills for reimbursement? Is there an online portal, or should I mail them?”
   • “What is the mailing address or website for submitting claims?”
   • “Is there a time limit for submitting claims after the date of service?”

Taking notes during this call will empower you to make an informed decision about your care.

Using HSA and FSA to Pay for Therapy

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) are excellent tools for managing therapy costs. These tax-advantaged accounts allow you to set aside pre-tax dollars to pay for qualified medical expenses, including counseling.

What are HSAs and FSAs?

• HSA (Health Savings Account): Available to individuals with high-deductible health plans (HDHPs). The funds are yours to keep, and they roll over each year if you don’t use them.
• FSA (Flexible Spending Account): An employer-sponsored account. You decide how much to contribute at the beginning of the year. Funds typically must be used within the plan year, though some plans offer a grace period or limited rollover.

How to Use Your HSA/FSA for Therapy

Using your HSA or FSA is simple. Most accounts provide you with a debit card that you can use to pay for your sessions directly at our office or through our online payment system. This allows you to pay with pre-tax money, which provides an immediate discount equivalent to your tax rate.

If you don’t have a debit card for your account, you can pay for your session out-of-pocket and then submit your superbill to your HSA/FSA administrator for reimbursement from your account.

Using these accounts is a smart financial strategy that makes investing in your well-being even more accessible.

Your Mental Health Is a Worthwhile Investment

Choosing a therapist is a deeply personal decision. By stepping outside the limitations of an insurance network, you give yourself the freedom to find a provider who truly understands you and has the specialized expertise to help you, your partner, or your family transform.

While navigating OON benefits requires a few extra steps, the return on your investment is immeasurable–stronger relationships, greater peace of mind, and the skills to navigate life’s challenges with confidence. We are here to support you not only in the therapy room but also in making your care as affordable as possible.

If you have any questions or need guidance, please don’t hesitate to contact us. We are ready to help you on your journey toward healing and connection.

Helpful Resources

• Couples Therapy
  Find support for relationships with compassionate, evidence-based couples counseling tailored to your unique needs.
• Individual Therapy
  Explore personal growth and emotional well-being in a confidential, supportive environment designed for individuals.
• Family Therapy in NJ
  Strengthen family bonds and navigate life’s challenges together with our inclusive, family-focused therapy services.
• New Client Hub
  Visit our New Client Hub–a welcoming center with resources, forms, and helpful information to guide you through your first steps as a new client.
• Therapist Matching
  Find the right therapist for your needs with our personalized matching service designed to support your unique goals and preferences.
• First Session Guide
  Curious about what to expect? This guide walks you through your first counseling session to help you feel prepared and supported.
• Telehealth Counseling Standards
  Learn about our secure, confidential virtual therapy options for convenient and effective care–wherever you are in New Jersey.
• Insurance Information
  Understand your insurance benefits, payment options, and how to make the most of your therapy coverage with our helpful overview.
• Contact Us
  Ready to take the next step or have questions? Connect with our team for guidance, scheduling, or more information. We’re here to help.

If you have additional questions or want to take the next step, please don’t hesitate to reach out. Your well-being matters to us, and we are here for you every step of the way.

At Maplewood Counseling, we are dedicated to supporting individuals, couples, and families in achieving mental wellness. Based in Maplewood, NJ, we proudly serve the Essex County, NJ community and offer statewide telehealth services to ensure accessible care for all. Whether you’re seeking help for anxiety, depression, relationship challenges, or personal growth, our experienced team is here to guide you every step of the way.

📠Location: 169 Maplewood Ave Suite 4 Maplewood NJ 07040
📞 Phone: 973-902-8700
🌠Website: Maplewood Counseling

We Use HIPAA Compliant Telehealth Platform SimplePractice for our Telehealth Sessions