LEGACY TRAILS
THERAPY, PLLC

We are currently IN-NETWORK with several (but not all) Blue Cross Blue Shield, Aetna, Curative, Optum, Meritain, UMR, Surest, Oxford, and United Healthcare plans. In-network typically means that you will pay a copay if you have met your deductible, pay a coinsurance rate, 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 "qualifying diagnosis," a necessary task for sessions to be covered and claims to be paid. Clients are responsible for the full rate if claims are denied.

Here’s a plain-language breakdown of some terms related to insurance:Premium: The fixed amount you pay each month to keep your health insurance active, whether you use it or not. It’s like a membership fee for your plan. For example, if your plan’s premium is $600/month and your employer pays $300, you pay $300. Even if you don’t see a therapist that month, you still pay your share to keep coverage.Deductible: The total amount you pay out-of-pocket for covered services each plan year before your insurance starts sharing costs. In therapy, this means you usually pay the full allowed amount per session until you meet your deductible. For example, if your deductible is $3,500, you would pay the contracted rate your therapist has with insurance until you've reached your deductible.Co-pay (Copay): A fixed, set amount you pay for a covered service at the time you receive it. In therapy, this is often a flat fee (e.g., $20–$50) per session, regardless of the actual billed amount.Coinsurance: The percentage of the allowed amount for a covered service that you pay after your deductible is met. For example, if your coinsurance is 20% and the allowed amount is $100, you pay $20 and your insurance pays $80.Qualifying Diagnosis: A medical condition or mental health diagnosis that your insurance plan recognizes as eligible for covered therapy services. Without a qualifying diagnosis, therapy may not be covered.Medical Necessity: The requirement that therapy is necessary and appropriate for your diagnosed condition, as determined by your plan’s criteria. This is often tied to your provider’s documentation and may require pre-certification.Claims: The formal request your provider submits to your insurance company for payment after you receive therapy services. It includes details like the date, provider, diagnosis, and allowed amount.Claims Denials: When your insurance company refuses to pay for a therapy session. Common reasons include lack of qualifying diagnosis, treatment no longer a medical necessity, or missing documentation. Denials can be appealed by the member.Identified Patient: The person whose insurance information is linked to the therapy session. Reimbursement Rates: Therapists are the lowest paid in the medical system for reimbursements, which is why most therapists do not accept insurance.

We encourage education and empowerment in and out of the therapy space. We want you to fully understand what your particular insurance plan covers, does not cover, and what you are paying for. We have a list of questions you can ask them directly (they answer the phone faster for their paying members than they do for the providers!). We will provide you with a script to verify your benefits before scheduling your intake session. We strongly encourage you to understand your benefits and what you are getting with your often costly payments for your insurance.Please Note:Insurance companies often restrict the systemic and evidence-based services family therapists can provide. Most insurance companies are not up-to-date on family therapy practices and still require an individual person (IP) to carry a diagnosis and receive the treatment within the relationship. Insurance companies want for the therapist to identify a single person in the family who is 'having' the problem 'for' the family. This is counterintuitive and often contraindicative for couple's work.In general, a mental health diagnosis is not always needed for a family to seek therapy, just like an illness is not always needed to try to improve overall health, but a diagnosis is required for billing insurance for any relational and/or individual work. We believe that overall wellness services should be provided with encouragement for those seeking a healthier lifestyle: especially in relation to how we raise our families. We also strongly believe in providing quality services and support to our community, many of which are looking to utilize their insurance for therapy services. We are more than happy to further discuss and explore if using insurance for therapy services is right for you and your family, partner, or relational dynamic at this time.

Please be advised that insurance companies restrict your therapist's ability to provide the very best treatment for your needs. A "qualifying diagnosis" is defined by insurance as a condition or disorder that significantly impacts an individual's functioning and for which treatment is deemed a "medical necessity."Insurance companies REQUIRE a qualifying diagnosis for coverage. This diagnosis becomes part of your permanent medical record and is necessary in order for your therapist to:Gain initial approval for coverage for psychotherapy appointmentsMaintain approval for ongoing session authorizationSubmit claims for processing and reimbursement, which can sometimes take months for the therapist to get paid for a single session.Only when absolutely necessary will therapists at Legacy Trails Therapy, PLLC, take a collaborative approach to diagnosis. Here is what that may look like:1) We openly discuss diagnostic criteria with you first.2) We conduct assessments as needed and discuss the risks and benefits of diagnosis. 3) If you have been diagnosed by another provider, please upload your documentation to your portal for your therapist to review. The diagnosis must align with the current content, process, treatment plan, and goals of your therapy at Legacy Trails Therapy, PLLC.​Because insurance companies REQUIRE that a diagnosis be determined the very first time we meet with a client for a session, the diagnostic process can be challenging for therapists and 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 determine medical necessity, so that your sessions are ultimately covered by insurance. If we are in-network and you've verified your benefits and uploaded the verification form to the portal, we can submit claims to your insurance company to seek reimbursement. In this case, we can use the balance from full-rate payments as credits for future sessions.​PLEASE NOTE: Although some mental health protections have increased over time, the assigned diagnosis may be relevant in determining future life insurance applications, certain employment screenings, or security clearances.

The answer is complicated. And, often times, no... and that answer may come later after several claims have been accepted, then denied.Many of our clinicians at Legacy Trails Therapy, PLLC, are trained to provide systemic relational/couples/family therapy, which is not the medical model that insurance requires us to follow.In order to submit claims to your insurance plan, some criteria must be met:In the diagnostic evaluation session (the first 55-minute therapy session), the therapist must determine a "qualifying diagnosis" for the insured or identified patient (IP).If the therapy is not focused on treating the symptoms related to the IP's diagnosis, we cannot submit claims as insurance will not cover these services, and you will be billed the full rate (i.e., communication issues, infidelity, desire discrepancy, "conscious uncoupling", sex therapy unrelated to a "qualifying diagnosis", etc.).If one partner is insured, that person is the IP. If other members of the relationship are not covered by insurance, they are not the IP. If all members of the relational dynamic are covered, there can be more than one IP.Therapists often conduct split sessions at the beginning of therapy to gather important information about each member/partner in the relational dynamic. Split sessions involve each partner meeting with the therapist to provide information about their family of origin, trauma, and other historical experiences of the lifespan. If a couple, for example, comes to family/relational therapy and the therapist recommends split sessions, insurance will only cover the sessions for their paid members. Example: Partners A and B come to therapy. The therapist wants to conduct split sessions with each member. Only Partner A is covered by insurance provisions. Partner B must pay the full out-of-pocket rate for the split session.During ongoing assessment throughout the therapeutic journey, the therapist may determine that the diagnostic criteria are no longer met due to progress. In this case, the therapist will inform the relationship members that sessions will need to be paid out of pocket.Self-Pay systemic/relational therapy that looks at the relationship holistically:Equity/equality in partner engagement and supportNo diagnosis requiredIncludes creative and effective approaches that support connection and repair between relational partners or family membersThe goal is to eliminate the need for an "identified patient," which decreases overall shame in the relational dynamicOUTCOME: Most effective approach for acute and ongoing relationship issues.​We recommend discussing your specific goals with your therapist to determine the best approach for your current needs.Please reach out if you have any questions: admin@legacytrailstherapy.com

Yes. At the outset of therapy, your insurance company REQUIRES us to agree to release the following (when audited or requested at any time for any reason):A diagnostic code describing your "qualified diagnosis"Your therapist's credentials and practice informationSession dates, frequency, and duration of your therapy sessionsTreatment plan goals and objectives related to your presenting concernsProgress notes indicating whether or not you're meeting treatment goalsBilling and payment information​Your therapist adheres to strict HIPAA guidelines and attempts to share minimal information necessary for billing and treatment authorization. Please be advised that your insurance company, as part of its contract with you that provides access to healthcare, has the right to conduct a more in-depth review. Your therapist will inform you of any requests made by your insurance company.

You have a few options if this occurs:OPTION 1: Pay the full rate initially, then...Request superbills from your therapist (if they are fully licensed) and submit each superbill to insurance so you can attempt to receive partial or full reimbursementSuperbills can sometimes lead to getting 20-100% back after meeting your deductibleSuperbills are only provided for full-rate payments and with fully licensed clinicians.Calculate your total annual costs compared to in-network options and see if there is much of a difference in the long run​​OPTION  2: Ask About Reduced-Rates or Sliding Scale SpotsSome out-of-network providers offer reduced rates (ask us about our student intern rates)Ask whether any of our Legacy Trails Therapy, PLLC, providers have reduced-rate openings for consistent self-payReduced rates or sliding-scale availability are based on financial hardship, and documentation is required for approval​​OPTION 3: Combination ApproachUse an in-network provider for individual psychotherapySee an out-of-network specialist for more complex or specific issues (trauma, couples therapy, sex therapy, etc.)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 worthwhilePlease feel free to reach out if you have any questions: admin@legacytrailstherapy.com

Every time you pay for a therapy session, it doesn't just cover the therapy session itself. There is a TON of behind-the-scenes tasks and obligations your therapist must meet to remain compliant with ethical, legal, and contractual standards. Anecdotally (and after a quick online search), one might observe that many therapists do not accept insurance for personal, professional, financial, and ethical reasons. Examples of why they opt out may include:inequitable, extremely low reimbursement rates for therapists, which leave them with less than an hourly minimum wagedifficulty receiving reimbursement payments in a timely manner. It can take anywhere from a few weeks to over a year (or longer) for therapists to get paid by insurance companies for the sessions they have with their clientsfear of insurance companies auditing client notes and documentation, which often include sensitive, personal informationextensive time, energy, and labor costs related to documentation, creating, submitting claims, and handling appeals when there are denials, phone calls, and LONNNGGG wait times (and getting hung up on or dropped call repeatedly), and verifying every client's very unique insurance plan and benefits. fear of misquoted network verifications (when the insurance company states that Legacy Trails Therapy, PLLC, is IN-NETWORK, then reverses payments with claw-backs, even though this mistake was due to the insurance company's representative's misquote!