Insurance, superbills and out-of-network couples therapy

Insurance is where couples therapy gets confusing. This guide explains the honest picture: most couples therapy is paid out of pocket, some therapists make insurance work, and some give you paperwork to try for reimbursement yourself. Nothing here is a promise that any plan will pay.

Does insurance cover couples therapy?

Usually not on its own. Health plans pay for treatment that is medically necessary for a diagnosed condition. Billing guidance for therapists explains that a plan pays “only when it deems the treatment medically necessary to treat a diagnosis of one member,” and that couples therapy is “typically not covered when the purpose of therapy is solely relationship growth or communication skills” (SimplePractice). A relationship-problem code on its own is generally not enough (ICANotes).

If you hear that “therapy is covered” on your plan, ask the plan specifically about couples sessions and the codes below.

When can insurance pay for couples sessions?

When one partner has a diagnosed condition and the couples sessions are part of treating it, a therapist may bill family psychotherapy:

• CPT 90847: family or couples psychotherapy with the patient present.
• CPT 90846: family psychotherapy without the patient present.

Both are billed under one partner, the “identified patient,” who holds the diagnosis. The diagnosis is part of that partner’s claim. Before choosing this route, ask the therapist and your plan who will see the claim and any statements.

How does in-network billing work?

If the therapist is in network with your plan, they bill the plan directly. You pay a copay or coinsurance per session, and the plan pays the rest at the rate it has agreed with the therapist. Being in network does not mean every session will be covered; the diagnosis and medical necessity rules above still apply. Headway, a company that helps therapists bill insurance, reports that roughly one third of therapists do not take insurance at all.

What is a superbill and how do out-of-network benefits work?

A superbill is a detailed receipt with the information your plan may ask for, such as dates of service and service codes. Ask your plan what it needs on a superbill. You pay the therapist their full fee, then submit the superbill to your plan yourself.

If you have out-of-network benefits, the plan may reimburse part of the fee after any deductible. The same diagnosis rule applies, so a superbill for couples sessions without a qualifying diagnosis is likely to be denied. AAMFT notes that some MFTs only take cash payment while others will file insurance, so ask how services are covered.

What should we ask our insurance plan?

Call the member services number on the card and ask:

1. Do I have outpatient mental health benefits, in network and out of network?
2. Are CPT codes 90847 and 90846 covered? (Asking about the codes can get a clearer answer than asking about “couples counseling.”)
3. What is my deductible, and how much of it is met?
4. What is the copay or coinsurance for in-network and out-of-network sessions?
5. Is preauthorization needed?
6. How do I submit a superbill, and how long does reimbursement take?

Write down the date, the name of the person you spoke to and a reference number.

What about EAPs, HSAs and FSAs?

• EAP. Headway, a company that helps therapists bill insurance, says Employee Assistance Program (EAP) sessions are typically free and don’t require a diagnosis, and that most plans offer three to eight sessions. Ask HR what your EAP includes and whether it covers couples sessions.
• HSA and FSA. The IRS says therapy qualifies if it treats a disease, but “an amount paid for marital counseling is not.” Check with your plan administrator.

What should we expect from a therapist on insurance?

Ask the therapist whether they bill insurance, give superbills, or neither. No one can promise that your plan will pay. SimplePractice, a practice-software company, says billing both partners’ plans for one couples session is double billing and can be treated as insurance fraud.

How will MarriageCounseling.io show insurance?

Each profile will show what the therapist states, with the date they confirmed it: self-pay fee, sliding scale, superbills, and any plans they are in network with. We will never label a therapist “covered by insurance,” because coverage depends on your plan and a clinical assessment. See also what couples therapy costs in California.