Updated December 26, 2019
Your health insurance benefits is limited to treatment that is considered a “medical necessity.” If you go for "couples therapy," your therapist must bill for relationship problems (Z63.0) as a "diagnostic code." They don't consider relationship problems a "medical necessity."
Health insurance will pay for a deviated septum, but not a rhinoplasty (nose job)." One is a necessity, one is not.
Straightforward "marriage counseling" is usually not covered in HSA's or FSA's in 2020.
Let's be honest.
We all pay a great deal for health insurance, and we all want our insurance providers to cover the maximum amount of services that we are entitled to.
However, it is important for those seeking couples therapy to understand what their insurance actually covers, and what it does not.
Does Insurance pay for couples therapy?
The question is a good one, and I'll walk you through how to find out, and how NOT to be stuck with a bill you didn't anticipate. But it's a long and twisted tale, so hang in...
Health Insurance companies have a “gag rule” that prevents therapists from telling you the truth about what's actually happening and why...I have no such limitation. I'll provide you with the information you need to make a good decision for your marriage.
And if they do, your therapist overwhelmingly will not be allowed to provide treatment in an evidence-based format that includes one hour-twenty minute sessions.
This is half the time they'll need to do an effective job in helping you heal and repair your relationship according to research on helping couples.
And, overwhelmingly, they will not be conducting effective science-based treatment.
And for intensive couples therapy, they'll pay usually no more than an session a day.
The Brake Job and The Dental “Eye Exam”
There are two stories that will help explain why your insurance company does not think the health of your marriage is any of their business.
Auto Insurance Coverage
The first one I borrowed (with permission) from Dan Stober (thank you Dan!). This is the short version. You can read the entire analogy at Dan Stober’s website.
I have coverage on my car and it costs a lot to insure that car every year. If I submit a claim for my brake job, they would reject the claim.
They would argue that “routine maintenance” is not covered in the contract. There is no disputing that you need routine maintenance, and without it, you’ll be more likely to cause accidents (when the brakes fail) but your auto coverage policy still won’t pay for it.
Optometrists don’t apply to Dental provider panels, even though both professions work on the face.
They are different skill sets.
I am a couples therapist.
If I apply to an insurance panel as a couples therapist, my application will be rejected.
Because Most Insurance Companies Don’t Cover Marriage Counseling.
They cover the treatment of mental illness. And they want generalists who can treat a wide variety of mental health issues.
If couples therapy is all I do, they don’t want me. They may want a marriage and family therapist (MFT) who can treat a variety of mental illness, but that's not the same as a "couples therapist" believe it or not.
MFT's may specialize in couples therapy, but most have taken only a single course in graduate school. They are trained to treat a variety of mental illnesses, and that is why they are accepted on that insurance panel.
You expect a professional to maintain integrity, and to practice within the bounds of their area of expertise.
Check the list of “specialties” in your Behavioral Healthcare Panel. You will see treatment for depression, childhood problems, ADHD, and all sorts of disorders. But you will see nobody listed as a specialist in “Marriage Counseling” or “Couples Therapy,” even if they claim to do marriage and family therapy.
Why? (sorry to be repetitive...)
Sounds silly, doesn’t it? Of course you wouldn’t.
And just as you would not expect your dentist to lie for you, neither should you expect your psychotherapist to, either.
You would not expect a professional to risk their license in order to save you some money.
What's more, you would be entitled to be angry for receiving substandard care, even if your insurance company completely covered it. Except chances are, you'd blame your marriage, not the therapist, and you might even divorce over it, thinking you "got help" and couldn't "be fixed."
Now imagine how getting substandard marriage counseling is impacting the lives of perhaps millions of people worldwide. You've just gotten a sense for why Couples Therapy Inc. exists.
Read your policy online and be familiar with what
each of these terms mean:
In-network (or Network) Provider
As Dan Stober says:
"Your health insurance is like that. The benefits may be limited to treatment that is considered a “medical necessity.” My health insurance will pay for my appendectomy, but not my face lift (or my marriage counseling)."
Here's a quote right out of the American Psychological Association ethics rules:
6.06 In their reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges, or payments, and where applicable, the identity of the provider, the findings, and the diagnosis.
Psychologists are ethically and contractually obligated to provide accurate information to the insurance companies they're paid by. You should know if you're given a diagnosis and you should know what services you're getting to treat that mental illness.
The services they provide you should not only be accurately stated, but it should reflect what services the therapist is actually providing.
Most insurance companies provide coverage for certain diagnoses and exclude other conditions. Psychologists may not submit false diagnoses or exaggerate their clients' problems in order to gain coverage or ensure continuation of coverage.
In other words, they can't make stuff up to get paid by your insurance company.
Second, health insurance companies pay for individual therapy only in 50 minute intervals. Evidence-based couples therapy happens in one hour 20-minute to one and a half-hour sessions.
You may get "lower cost treatment" but it may be ineffective help.
Think about that for a minute.
Would you buy an inexpensive car that didn't run?
A toaster that only burned toast?
And yet, week after week, year after year, couple do to ineffective therapy with untrained professionals working half the time needed to get real help.
Longer sessions for couples therapy just makes sense. If you have two people in a room, they will require more time to effectively help than one person and one therapist.
Simply put, if you go for "couples therapy," your therapist must bill for couples therapy (Z63.0) and treat your relationship problems. If they find that couples therapy is inappropriate for you, they should recommend a more appropriate service and provide that or refer you to someone who can. If you're too depressed, anxious, or problematic in some way to benefit from couples therapy, they should tell you that, and refer you for treatment.
But "claiming" you are anxious, depressed, or have an "adjustment disorder" in order to provide help for your relationship is just plain wrong and may have serious implications to your life later down the road. Accepting a diagnosis of a mental disorder should be taken seriously. And you should know when you are given one.
Couples therapy isn't individual treatment with two people. It's different. Couples therapy treats couples for relationship problems. It doesn't label one of you as "the problem," even though each of you may have problems of your own. It treats you as a dynamic "system" that needs to be worked on in order to work more effectively.
Loneliness isn’t a “disease.” (click to learn more.)
Many clients were surprised to learn that they were given a mental illness diagnosis. They went for help for their marriage, and did not consider themselves mentally ill.
Things change frequently. What was acceptable last year may not be this year. In years past you could include in medical expenses amounts you pay for therapy received as medical treatment. This includes sex therapy by a psychologist or psychiatrist for medical reasons. Recent changes make that questionable.
Straightforward "marriage counseling" is usually not covered in HSA's/FSA's. Treating sexual problems or sexual incompatibility is more likely to be covered as well. Ask your Accountant or Compensation and Benefits Administrator if you qualify for either program.
A large percentage of people who are seeking a therapist do so because they want help with their marriages.
Insurance companies, by and large, do not cover the cost of this type of treatment. They don’t have to.
And they are increasingly clamping down on therapists who claim to practice couples therapy, while billing your insurance company as if they are treating one of you as an individual, not part of a couple.
And there you are, the couple in a troubled marriage, receiving treatment, and your therapist simply stops seeing you.
Or goes into limbo and doesn’t tell you why.
Or sees you for 1/2 the 90 minute session, and won’t even LET you pay for the other half out of pocket.
They can’t tell you why because of the gag rule they signed.
And perhaps in 6 months, they go out of business…
In fact, it is happened recently in New England to about 50 psychotherapy practices. Health New England is one company. You will not hear anything about why your couples therapist has stopped accepting Health New England, because they have a “gag rule” that prevents your couples therapist from telling you the truth, but here it is:
HNE doesn’t PAY for couples therapy and never has. And now they’ve decided that they need additional revenues, so they sent a letter and told your couples therapist: “We’re holding back tens of thousands of dollars from you, Dr. therapists, because you’ve misused 90847. And billed us ‘incorrectly.'”
“I’ll (the insurance company) ignore what you (the therapy agency) is doing, because our subscribers like couples therapy..."
Should insurance companies run into financial problems with their investments they can always say:
Wait, I've changed my mind..."...and the therapist simply stops seeing you, and can't tell you why, because they've signed a "gag rule clause."
The reason is simple: If your insurance provider finds this kind of insurance misuse, it might be months before they retroactively refuse to pay for sessions they inadvertently ALREADY paid for.
That means they might pay the claim today, but demand payment from the therapist tomorrow. It is called a “claw back,” and it happens routinely, especially to large group practices, once yearly audits occur.
For this reason, most therapists have clients sign a document indicating that if an insurance claim is denied, the client is still responsible for payment.
You should check carefully ahead of time, to avoid what happened to John and Sheila (the story that follows) from happening to you.
Let’s follow along as one couple tried to get payment for couples counseling from their insurance company, and thought they had all of their bases covered:
Waiting to talk to a human being at the insurance company, John heard a recording that went something like this:
“A quote of benefits or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service.”
Your medical insurance pays for what they consider to be “medically necessary.”
John was too upset to sleep one night, after a big fight with his wife, so he read the member’s contract aka “his insurance policy,” from cover to cover. He read that they will pay only for what they consider to be “medically necessary.” This means that they have the right to withhold payment if it is considered outside the scope of the policy.
This is true even if they tell you, in a telephone call, that you are covered for that service.
Will it be covered under his policy? The person on the other end of the telephone told him they cover couples therapy. He even got an authorization number. He’s all set to go, right?
Probably not, and here’s what happens:
If John had severe depression, his therapist might ask his wife to join them...She would be there as a "collateral." A collateral is usually a spouse, family member, or friend, who participates in therapy to assist the identified patient. The collateral is NOT the patient.
If John had a severe depression, his therapist might ask his wife, Sheila, to join them for several sessions. She would be there as a “collateral,” and this would be fully covered. A collateral is usually a spouse, family member, or friend, who participates in therapy to assist the identified patient. The collateral is not considered to be a patient and is not the subject of the treatment, nor are they responsible for payment.*
Having a parent there for a child’s treatment, or a family member there to help another person with their mental disorder would be billed under the Procedural Code 90847: “Family psychotherapy, conjoint psychotherapy with the patient present.”
John is the “patient.” His depression is the “Diagnosis.”
This is not couples therapy session.
The focus of treatment is NOT on their marriage.
Why does it matter if the focus is on the marriage, and not the individual?
It’s the difference between remaining happily married, and staying married at all. Read more here.
If your therapist is planning to submit a bill for anything other than a Z-code, one of you is the patient. It is important to know who that is, and what illness you are being treated for. And a treatment plan for that illness, as well.
Many clients were never told this fact, and were surprised to learn that they were given any mental illness diagnosis at all, when they just went for marriage counseling.
John found a therapist in his plan and he and his wife went to treatment. They have a $30 co-pay, which they paid at the time they were seen. They were seen for 50 minutes, which is what their insurance would reimburse.
The therapists, who is an “in-network provider,” then sent a bill to his insurance company for the balance. That claim includes information about
There are many good reasons why insurance would pay for a family member to be seen. Those with schizophrenia might be helped if their parents understood more about the disorder, and how to remain calm and not overly emotional, when psychotic episodes flare up. This is important psycho-education.
So what about couples therapy?
Simply put, a collateral is a helper. Parents go to "play therapy" to get guidance as to how to best handle the child, but it is billed under the child's diagnosis. The parent is only there as a "helper" or "interested party."
The collateral is NOT the patient.
This is the most confusing part to most people. Your insurance will pay for both spouses being in the room (Procedural Code) and the clerk on the phone will say “Yes, we cover couples counseling,” because they see the Procedural Code “Couples/Family Therapy” on their computer screen. But a Procedural Code (Who’s in the Room) doesn’t kick out the claim. It is the Diagnostic Code that causes the claim to be rejected.
Back to John and Sheila…The claim is probably submitted electronically, and the processors in the claims department of John’s insurance company reviewed the claim to insure accuracy in reporting and to determine if the treatment identified falls within the scope of the contract (“the insurance policy”).
They do not consider your marriage counseling to be a "medical necessity."
So because John and Sheila came in for help in managing their marriage, fights, or their sexual issues, the appropriate code is Z63.0 Relationship Problems.
When the processor at the insurance company reviewed this claim (or more likely their computer program does…), they send a letter stating that the claim will not be paid because it falls outside of the scope of the member’s contract. They do not consider John and Sheila’s marriage counseling to be a medical necessity.
Therefore John and Sheila owe the therapist for payment. And they have agreed to pay for their session if their insurance does not.
Having taught the DSM in a Marriage and Family Therapy program, I know the literature. Z-codes are just as serious and the distress is just as great, as other codes in the DSM/ICD-10. However, this bias against the use of Z-codes are almost universal. They are treated as somehow “less problematic” than other diagnostic categories. This is, again, unfortunate.
I’ve put language for you to look for in policy at the end of this document as well.
Is “bad marriage therapy” worse than “no marriage therapy?” Read what one expert in the field has to say here.
“Do you pay for marriage counseling?” because they may say “Yes,” meaning “You both can be there in the same room.”
You now know that that’s called a Procedural Code, (the procedural code for couples or family work is 90847, and it pays for 50-minutes of treatment).
“Do you pay for the Diagnostic Codes Z63.0?” (You can see a list of all DSM-V/ Z-codes here.) (ICD-10 Codes and DSM-5 Code: V61.1 Counseling for marital and partner problems)
Make them look it up. Don’t settle for some general answer like “We pay for all the codes.”
If you check ahead, at least then you know whether your couples therapy sessions will be legitimately paid for, and you won’t be stuck with an unexpected bill in the future.
If they say “Yes!” you are all set. You have a rare executive policy that plan that covers Marriage Counseling. Be sure to ask how many sessions they will cover. For some, I have found it is as short as 3-4 sessions. For others, they will pay for up to 10 sessions before they expect another diagnosis to be given.
This is, again, unfortunate.
Want to know how to find a skilled couples therapist? Read more here.
Many people do not want to be labeled with any sort of mental disorder because they are concerned about the impact these labels will have on other aspects of their lives. But even those who have such diagnostic labels often do not want their diagnosis to be the focus of their couples treatment.
Sometimes their spouses have blamed them unfairly, for years, as being “the problem” in the marriage. While prior bouts of mental illness can sometimes be an issue in marriage, this isn’t always the case. Most of us seeking couples therapy do not want to be considered “the problem” in the marriage. They want to be considered an equal participant, a sane person, who should be respected and listened to, not labeled the “sick one” (however benevolent the intentions might be) who needs help.
Sometimes a spouse will have an undiagnosed mental disorder. A thorough evaluation will determine this. If so, they will be referred to a skilled practitioner who will provide them with appropriate treatment, and their health insurance provider will be billed. This is appropriate and often very helpful to the couples therapy.
I guess the answer to that depends on your politics. If 40% of people looking for help are looking for couples therapy, that is a lot of payouts, and that means insurance premiums may rise.
Dr. K served on the Executive Board of the Massachusetts Chapter of the American Association for Marriage and Family Therapists for three terms. Our mission was to explore how to provide couples counseling to everyone. An argument can be made that functioning, healthy families reduces overall medical costs.
But we believe we are a long way off from seeing that goal become a reality. Much as we all might wish it were so.
“Mental health treatments for Z-code conditions as listed in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association which, according to the DSM, are not attributable to a mental health disorder or disease are excluded.
“Additional Information: The lack of a specific exclusion of a service does not imply that the service is covered.
“The following are examples of circumstances under which mental health treatments for a Z-code condition are excluded (not an all inclusive list).
The problem is the focus of diagnosis or treatment and individual has no behavioral health condition (e.g., a Partner Relational Problem in which neither partner has symptoms that meet criteria for a behavioral health condition).
The individual has a behavioral health condition but it is unrelated to the presenting problem (e.g., a Partner Relational Problem in which one of the partners has an incidental behavioral health condition), and the problem – not the behavioral health condition – is the focus of diagnosis or treatment.”
*unless they are legally responsible for the client. A parent, for example, is a collateral to children seen in therapy.