Quick Guide to Navigate Out-Of-Network Mental Health Insurance Benefits

Insurance can be confusing, especially when you’re trying to figure out if therapy will be covered. The good news? Even if a therapist isn’t “in-network,” many plans still reimburse part of the cost. That means you may be able to choose the therapist who’s the right fit for you and get money back from your insurance.

This guide walks you through how out-of-network (OON) benefits work, key terms to know, and what to ask your insurance company.

Why Choose an Out-of-Network Therapist?

In many cities, in-network therapists are booked up with long waitlists. Going out-of-network gives you more options and lets you choose a therapist based on fit, not just availability on a list.

With OON benefits, you pay your therapist’s fee up front, then submit for partial reimbursement from your insurance. Many clients are surprised to learn they can receive 30–80% back on therapy costs.

How Reimbursement Works (Step-by-Step)

1. Pay your therapist directly at the time of session.
2. Receive a “superbill.” This is a special invoice with all the codes and info your insurance requires.
3. Submit the superbill to your insurance provider (often online through a member portal).
4. Get reimbursed based on your plan’s OON coverage.

Key Terms to Know

• Out-of-network deductible: The amount you pay out of pocket before insurance begins to reimburse. Example: if your OON deductible is $1,000, you’d cover that amount first, then insurance starts paying its share.
• Co-insurance: The percentage you pay after meeting your deductible. Example: if therapy is $200 and your co-insurance is 30%, you’d pay $60 and insurance would reimburse $140.
• Copay: A fixed amount you pay per visit (less common with OON).
• Out-of-pocket max: The maximum you’ll pay in a year before insurance covers 100%. Some plans have a separate OON max.
• Pre-authorization: Some insurers require approval before covering certain therapy codes.

What Is an Out-of-Network (OON) Exception?

In some cases, your insurance company may grant an out-of-network exception (also called a network gap exception or single case agreement).

This happens when your insurance plan doesn’t have any in-network therapists who can reasonably meet your needs. For example, no one may be available in your area, have openings, or specialize in your cultural background or concern.

When approved, an OON exception lets you see your chosen therapist at in-network rates. That means:

• You would pay only your in-network copay or coinsurance, not the higher OON rate.
• Sessions would apply toward your in-network deductible and out-of-pocket maximum.

How to request one:

1. Call your insurance company and explain why you can’t find an in-network provider who meets your needs.
2. Be specific (e.g., “I need a South Asian therapist,” “I need someone specializing in anxiety and burnout,” “No one has openings within the next two months”).
3. Ask if they offer a network gap exception or single case agreement.
4. If approved, your therapist may need to complete paperwork to finalize it.

Questions to Ask Your Insurance Company

When you call the number on the back of your card, here are key questions to ask:

1. Do I have out-of-network benefits for outpatient mental health visits?
2. What is my OON deductible, and how much of it has already been met this year?
3. What is my co-insurance or copay once that deductible is met?
4. Do I have an out-of-network out-of-pocket maximum?
5. Do I need pre-authorization for the following codes?
   1. 90791 (Initial Assessment)
   2. 90837 (50-minute session)
6. Is there a limit on the number of sessions covered per year?
7. Does my plan cover telehealth therapy sessions?
8. How do I submit claims for reimbursement?

Final Thoughts

Navigating insurance can feel overwhelming, but once you know the right questions to ask, the process becomes much clearer. Many clients discover that using OON benefits or requesting an OON exception makes therapy more affordable than they expected.

At the end of the day, therapy is about finding the right fit, not just the right network. With the right information, you can access the support you need while making the most of your insurance benefits.

Have more questions or want to see if we’re a good fit? Contact Arati to schedule your free 15-minute consultation.