LEGACY TRAILS
THERAPY, PLLC
LEGACY TRAILS THERAPY
F A Q s:
Insurance
What insurance plans do you currently accept?
We currently accept many (but not all) Blue Cross Blue Shield, Aetna, Optum, Meritain, UMR, Oscar, 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.
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.
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 there is a justifiable medical necessity that can be addressed through relational work in therapy (i.e., depression or anxiety impacting the relationship). This contradicts what systemic family therapy is, which often creates a barrier for therapists to be able to truly help the relational dynamic.
Here are some examples of situations where it might be more likely to be covered:
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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).
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Couple's Therapy: A couple is moving through struggles after the death of a child and need therapy for grief and loss.
We recommend checking with your insurance directly about coverage for relationship-related therapy services.
Can I switch from insurance to self-pay or vice versa during treatment?
Yes, but there are important considerations described below.
Switching to Self-Pay:
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Usually straightforward - just notify your therapist and/or billing admin
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May qualify for reduced rate spots if available
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Eliminates insurance reporting requirements
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Previous insurance claims remain on your record
Switching to Insurance:
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Requires establishing medical necessity and qualifying diagnosis for record and billing
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May need prior authorization, depending on your insurance plan
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Could involve waiting periods for openings of therapists taking insurance clients
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Previous self-pay sessions will not be reimbursed
Timing Considerations:
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Best to decide before starting treatment when possible
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Mid-treatment switches will require new paperwork and treatment plans
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Some therapists have different rates for insurance vs. self-pay clients
Discuss any desired switches with your therapist early to ensure smooth transitions without interrupting your care.
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:
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Initial coverage approval
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Ongoing session authorization
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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.).
When appropriate, 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 of 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.
Insurance companies often require a diagnosis on the first visit. This is challenging for therapists and can lead to inaccuracies and harm. Our therapists may need to charge their full rate for the first 1-3 sessions to better understand your needs and medical necessity. If we are in-network, and you have verified benefits, we can bill those sessions and use the excess as credits for future sessions.
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 a record of:
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Your diagnostic code
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Therapist credentials and practice information
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Session dates, frequency, and duration
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Treatment plan goals and objectives
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Progress notes indicating you're meeting treatment goals
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Billing and payment information
Your therapist follows strict HIPAA guidelines and attempts to share only the minimum information necessary for billing and treatment authorization; however, audits may require more invalsive review by your insurance company.
My partner and I want couple's therapy, what are our options at Legacy Trails Therapy?
Option 1 - Insurance-covered therapy that focuses on an individual's symptoms that impact on the relationship:
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Potentially covered by insurance (dependent upon the plan): This can be covered if the insured individual has a (required) qualifying diagnosis affecting the relationship and is using that for relational therapy (not for individual therapy already in progress)
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Outcome: Very limited effectiveness compared to true systemic therapy
Option 2 - Self-Pay systemic/relational therapy that looks at the relationship holistically:
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Equity/equality in partner engagement
- No diagnosis required
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Outcome: More effective approach for acute and ongoing relationship issues
We recommend discussing your specific goals with our therapists to determine the best approach for your current needs.
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.
OPTION 1: Pay the Full Rate Initially, then...
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Request superbills from your therapist (if they are fully licensed) and submit to insurance to attempt to receive partial reimbursement
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Superbills can sometimes lead to getting 50-80% back after meeting your deductible
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Calculate your total annual costs compared to in-network options and see if there is much of a difference in the long run
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PLEASE NOTE: Superbills are only provided for full-rate payments and with fully licensed clinicians.
OPTION 2: Negotiate Rates
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Some out-of-network providers offer reduced rates (ask us about our student intern rates)
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Ask whether any of our Legacy Trails Therapy providers have reduced-rate openings for consistent self-pay. Reduced rates or sliding-scale availability are based on financial hardship, and financial documentation is required for approval.
OPTION 3: Request Single Case Agreement
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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)
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This requires documentation of unique circumstances or specialization needs
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Success varies by insurance company and situation
OPTION 4: Combination Approach
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Use an in-network provider for basic therapy
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See out-of-network specialist for more complex or specific issues (trauma, couples work, etc.)
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The out-of-network provider you prefer may offer more specialized training, increased availability, or treatment approaches not available in-network, making the additional cost worthwhile.
Why Don't Many Therapists
Accept Insurance?
Every time you pay for a therapy session, it does not just cover the 53-60 minutes with your therapist. There is a LOT of behind-the-scenes work that therapists have to do to remain in compliance with ethical and legal standards.
Anecdotally speaking (and upon anyone doing a simple search online) one can gather that many therapists do not accept insurance for personal, professional, and ethical reasons, including (but not limited to):
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inequitable and extremely low reimbursement rates for therapists, often leaving them with less than an hourly minimum wage
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Difficulty receiving reimbursement payments in a timely manner (it can sometimes take several months or up to a year or more in certain circumstances for therapists to be reimbursed for their work by some insurance companies)
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Fear of insurance companies auditing client notes, which often include sensitive information
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Extensive time, energy, and labor costs related to documentation, creating, submitting claims, handling appeals when there is a misquote from an insurance provider, clawbacks (even when the insurance company makes the mistake), making phone calls to dispute denials, verifying each client's unique plan to see if there are restrictions with mental health benefits, etc.