Understanding Out-of-Network Benefits

The first step to navigating insurance is understanding the difference between in-network and out-of-network benefits. Here’s a quick guide to how out-of-network benefits work. Read about in-network benefits here.

An out-of-network provider does not have a contract with your insurance company. If a provider tells you that they do not take your insurance, you may still be able to use out-of-network benefits to pay for care with them.  

When your child gets care from an out-of-network provider, you pay the entire cost of the session upfront. Then, you file a claim with your insurance company and they reimburse you for some of the money you spent. Filing a claim means filling out paperwork about the care your child received and sending it to the insurance company, usually by mail. Your provider will give you a document called a superbill to include with your claim. A superbill shows the company exactly what kind of care your child got. 

There are several factors to consider when looking at the cost of out-of-network care: 

• Insurance companies usually cover less of the cost of an out-of-network provider. For example, you might have to pay a $25 copay if you see an in-network provider but a $35 copay if you see an out-of-network provider. 
• Insurance companies do not usually reimburse you based on the amount you actually paid your provider. Instead, they reimburse you based on what’s called the allowable amount for the service your child received. The allowable amount is the amount that your provider has decided it is reasonable for a provider in your area to charge for a specific service. For example, your insurance company’s allowable amount for one individual psychotherapy session may be $100. If your child’s therapist charges you $125 for that session, your insurance company will still reimburse you as if the cost were $100. 
• The deductible still applies for out-of-network care. You will not be reimbursed for your child’s care until your deductible for the year has been met. 

The upside of using out-of-network benefits is that they usually make finding care much easier. You have more providers to choose from, and your child can likely start getting care sooner because you won’t run into as many waitlists. 

The downside is that getting care using out-of-network benefits is almost always more expensive. You have to pay for sessions upfront and getting reimbursed by your insurance company can be complicated and time-consuming. 

It’s also common for insurance companies to reject claims for out-of-network benefits, even if the care should be covered under your plan. The most common reasons that claims are rejected are small errors like misspelled names or wrong birthdates. If you do use out-of-network benefits, be sure to check all the details on your claims carefully.  

You could also consider using a service that deals with claims for you, like the Reimbursify app. These services charge a small fee in exchange for helping you get reimbursement from your insurance company, so they may help you get more money back in the long run.  

Return to Connect to Care for more information about getting kids help.