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F A Q s:

Insurance

What insurance plans do you currently accept?

We currently accept many Blue Cross Blue Shield, Aetna, Optum, Meritain, and United Healthcare plans. We are in-network with these providers, which typically means that you will pay a copay if you have met your deductible, or you may have to pay a contracted rate that goes toward your deductible. 

 

Even if we're not in-network with your insurance plan, you may still have out-of-network benefits that might help cover the cost of therapy. You will need to contact your insurance provider directly to determine what the process is for out-of-network benefits. Upon request, we can provide you with a superbill (detailed receipt) to submit to your insurance for potential reimbursement for full rate sessions.

 

Please note that using insurance REQUIRES a therapist to conduct a diagnostic assessment to determine a diagnosis, a necessary process in order for sessions to be covered.

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Does insurance cover family/couples/relationship therapy?

Insurance coverage varies significantly between individual and relational therapy. Most insurance plans readily cover individual therapy when there's a qualifying mental health diagnosis and medical necessity.

 

However, relational therapy is not covered unless one partner or family member has an individual diagnosis (and medical necessity) that can be addressed through relational work in therapy (i.e., depression or anxiety impacting the relationship).

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Here are some examples of situations where it may be more likely to be covered:

  • Family Therapy: A child or adolescent is the identified patient ("IP") with a qualifying diagnosis and family involvement is medically necessary for treatment (i.e., a teen in recovery from anorexia nervosa and needing family therapy as part of the relapse prevention and step-down process from an inpatient program).

  • Relational Therapy: The provider can ethically and accurately use specific billing codes that your insurance plan accepts (this varies across plans).

  • Couple's Therapy: A couple is moving through struggles after the death of a child and need therapy for grief, loss, and reconnecting during this transitional time.

 

We recommend checking with your insurance directly about coverage for relationship-related therapy services.

What does in-network vs. out-of-network mean?

​In-network:

  • If we are in-network with your BCBS, Aetna, Optum, Meritain, or United Healthcare plan, that means that we are under contractual obligations to provide eligible therapy services with specific guardrails and expectations. This results in:

    • Lower out-of-pocket costs (just your copay - usually $10-$50, sometimes more, sometimes less depending on your insurance plan and deductible)

    • No claim-related forms that you have to submit (our insurance specialist submits on our end)

    • Predictable costs 

    • A required diagnosis

    • Limited frequency and duration of sessions depending on your plan

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Out-of-network:

  • If we are considered out-of-network for your insurance plan, you do have options:

    • ​Potentially more experienced or specialized providers who are not under contract with insurance companies

    • Higher initial costs (full rate is paid at time of session)

    • Potential reimbursement through your out-of-network benefits (typically 50-80% after deductible)

    • More flexibility in treatment approaches

    • You will have to submit superbills (detailed receipts paid at full rate) to your insurance for reimbursement when seeing out-of-network providers

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Can I switch from insurance to self-pay or vice versa during treatment?

Yes, but there are important considerations described below.

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Switching to Self-Pay:

  • Usually straightforward - just notify your therapist and/or billing admin

  • May qualify for reduced rate spots if available

  • Eliminates insurance reporting requirements

  • Previous insurance claims remain on your record

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Switching to Insurance:

  • Requires establishing medical necessity and qualifying diagnosis for record and billing

  • May need prior authorization, depending on your insurance plan

  • Could involve waiting periods for openings of therapists taking insurance clients

  • Previous self-pay sessions will not be reimbursed

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Timing Considerations:

  • Best to decide before starting treatment when possible

  • Mid-treatment switches will require new paperwork and treatment plans

  • Some therapists have different rates for insurance vs. self-pay clients

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Discuss any desired switches with your therapist early to ensure smooth transitions without interrupting your care.

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Image by Shannon Potter
Do I need a mental health diagnosis to use my insurance?

Yes, insurance companies REQUIRE a qualifying mental health diagnosis for coverage. This diagnosis becomes part of your permanent medical record and is necessary for:

  • Initial coverage approval

  • Ongoing session authorization

  • Claim processing

Common diagnoses that significantly impact individual functioning, and are medically necessary, are considered "qualifying mental health diagnoses" (i.e., anxiety, depression, personality disorders, etc.).

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Therapists at Legacy Trails Therapy, PLLC take a collaborative approach to diagnosis: We openly discuss it with you first, conduct assessments as needed, and discuss the risks and benefits to diagnosis. If you have been diagnosed by another provider, please upload your documentation into your portal for your therapist to review. The diagnosis must align with the content, process, treatment plan, and goals for it to be ethically considered.

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PLEASE NOTE: Although some mental health protections have increased over time, the diagnosis may be relevant for future life insurance applications, certain employment screenings, or security clearances.

What information does my insurance company receive about my therapy?
At the outset of therapy, your insurance company will have record of
  • Your diagnosis code
  • Therapist credentials and practice information
  • Session dates, frequency, and duration
  • Treatment plan goals and objectives
  • Progress notes indicating you're meeting treatment goals
  • Billing and payment information
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Your therapist follows strict HIPAA guidelines and attempts to only share the minimum information necessary for billing and treatment authorization.
My partner and I want couple's therapy, what are our options at Legacy Trails Therapy?

Option 1 - Insurance-covered therapy that focuses on individual impact on relationship:​

  • Potentially covered by insurance (dependent upon the plan): This can be covered if the insured individual has a (required) qualifying diagnosis affecting the relationship

  • Outcome: Very limited effectiveness compared to true systemic therapy

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Option 2 - Self-Pay systemic/relational therapy that looks at the relationship holistically:

  • Equity/equality in partner engagement

  • No diagnosis required

  • Outcome: More effective approach for acute and ongoing relationship issues

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We recommend discussing your specific goals with our therapists to determine the best approach for your current needs.

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What if my insurance plan changed and now my therapist is out-of-network. Can I still work with my therapist?

You have several options here, depending on your current insurance plan and changes.

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OPTION 1:​ Pay the Full Rate Initially, then...

  • Request superbills from your therapist (if they are fully licensed) and submit to insurance to attempt to receive partial reimbursement

  • Superbills can sometimes lead to getting 50-80% back after meeting your deductible

  • Calculate your total annual costs compared to in-network options and see if there is much of a difference in the long run

  • PLEASE NOTE: Superbills are only provided for full rate payments

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OPTION  2: Negotiate Rates

  • Some out-of-network providers offer reduced rates (ask us about our student intern rates)

  • Ask if any of our Legacy Trails Therapy providers have reduced rate openings for consistent self-pay

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OPTION 3: Request Single Case Agreement

  • Your insurance might make an exception if there are no in-network providers that meet your specific needs in your area (if in person only)

  • This requires documentation of unique circumstances or specialization needs

  • Success varies by insurance company and situation

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OPTION 4: Combination Approach

  • Use an in-network provider for basic therapy

  • See out-of-network specialist for more complex or specific issues (trauma, couples work, etc.)

  • The out-of-network provider you prefer may offer more specialized training, better availability, or treatment approaches not available in-network, making the additional cost worthwhile.

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