Navigating Health Insurance When You Need Specialized OCD Treatment

Let’s begin on a positive note: it’s great that your insurance will cover some or even all of your sessions because, frankly, it hasn’t always been that way. For a long list of reasons, access to care for serious mental health disorders—including OCD—has lagged far behind that of physical ones. Even compared to other mental health conditions, access to specialized care for OCD has been limited. Expanding that access is essential to everything we do at NOCD. In fact, it’s the reason we exist. 

The gold standard treatment for OCD is called exposure and prevention response therapy (ERP). With most OCD specialists outside of NOCD, it’s expensive. (You can read about why that is here.) It’s nearly impossible to overstate the impact that more insurers covering specialized OCD care is having on our community. Putting specialized OCD in people’s reach is transforming lives every day. 

So let’s now address the defining characteristic of healthcare in the United States: its complexity. In an ideal world, having health insurance would eliminate the stress of not knowing exactly how much you may need to pay out of pocket for your care. In that same ideal world, we’d be able to tell you how much your care will—or won’t—cost you before your first session.  

Unfortunately, we’re unable to do that because your insurer only tells us exactly how much of your care they will cover after you do your session and we’ve submitted a bill to them. Your insurer will then review that bill, see how it squares with your plan, and figure out how much you owe based on some of the variables we’ll get into in a moment. That process can take several weeks.

We understand that not knowing exactly how much you’ll be responsible for until weeks into your recovery is a daunting prospect. Many of us at NOCD have been in exactly the same boat.  

What we can do is give you some help with understanding the factors that will affect how much your insurance will cover and how much will be your responsibility. We know that getting your life back from OCD is important. We’re here to do whatever we can to make your recovery easier.  

Deductibles

One of the main things that will ultimately affect how much you owe is your annual deductible. A deductible is the amount of money you have to pay out of pocket before your insurer begins covering any of the cost. Before  meeting the out of pocket deductible you’ll be responsible for most of the total charges. Typically, before to the deductible is met,  a health plan covers 20% of the charges and you’ll be responsible for 80%.

Typically, a low annual deductible plan will have a higher premium. (An insurance premium is a monthly amount that you and/or your employer pays the insurer.) Plans that have a lower monthly premium typically have a higher deductible. 

Once a deductible has been met the percent coverage usually flips. 80% is covered  your by health plans and 20% is on you. 100% insurance coverage is usually only granted when the total out of pocket maximum has been reached.

What makes things slightly more complex is that your annual mental health benefits (sometimes referred to as behavioral health benefits) are different from your physical health benefits. That means that your mental health deductible will be separate too. Let’s look at a mental health deductible in an example. 

Carol has a mental health deductible of $500. Earlier this year, she had three therapy sessions that cost her $110 each. By the time she joined NOCD, she still had $170 left in her deductible. Her first session with one of our OCD specialists cost $170, all of which was Carol’s responsibility. But from that point on, Carol’s insurer began to cover her treatment because she’d met her annual mental health deductible of $500.   

We encourage you to call your insurance provider and ask them if you have met your mental health benefits deductible. You should also know that some plans don’t have any deductible. If this applies to you, you’ll just pay the copay for every session. 

Copays

A copay is a flat fee that you pay for a healthcare service. Depending on your plan, it might be a modest or not-quite-so-modest amount. Copays typically start at around $10 per visit and go up from there. They are paid at the time that you receive care. 

A copay can take effect before or after you’ve reached your annual deductible, though they generally don’t count towards that deductible. Copays are one way insurers share the cost of medical services. Your copay for primary care visits, specialist visits, prescription, and generic drugs can often be found on your insurance card. If it’s not, call your insurer to find out what that copayment is and whether it takes effect before or after your deductible is met. 

When we left Carol, she had met her annual mental health deductible of $500, and her insurance would now cover almost the entire cost of her sessions going forward. Carol’s only outlay for the rest of the year is her $20 copay, which she pays at the end of each session.   

Coinsurance 

Another way that insurers share the cost of medical services is coinsurance. After you’ve met your deductible, coinsurance is the percentage of covered medical expenses that you’re responsible for. For example, if you have an 80/20 plan, the insurer pays for 80% of your care while you are responsible for paying the remaining 20%. Many plans have something called an out-of-pocket maximum. If and when you hit that limit, your insurer will cover the total cost of your care. This will include copays, deductibles, and coinsurance amounts, but not the monthly premium. 

However, something to be aware of is that coinsurance only applies to covered services. You’ll be responsible for the entirety of your bill if you have expenses that your plan doesn’t cover. 

If you’re unsure which services your plan covers, look over your benefits booklet or call your plan provider.

Like Carol, Justin has a $500 mental health deductible. He doesn’t have a copay but has an 85/15 coinsurance plan. Once he met his $500 deductible, Justin’s insurance started paying for 85% of his sessions, and Justin paid the remaining 15%. 

In-Network vs. Out-of-Network

Something else that can affect how much money your care will cost you is whether the provider is in-network or out-of-network.  (A provider simply means the person or facility that is delivering your care. Your doctor, your dentist etc). 

In-network providers are care providers with which your insurer has negotiated lower rates. As you’ve already deduced, out-of-network providers are going to be pricier than in-network providers. The good news is that the number of in-network providers is steadily growing and that growth is set to continue.

When you have OCD, you’re predisposed to looking for certainty. Unfortunately, the world of health insurance offers very little of that. That being said, we’re thrilled that you are here and ready to get care. We’re here to make getting that care as easy and transparent as possible.

If you’re looking to find an affordable and effective way to manage your OCD, book a free 15-minute call with our team to learn more about working with a NOCD therapist.