Navigating Medical Necessity and Insurance

For as long as you can remember, you’ve had a desire to go to counseling. You’re finally ready to take the next step but are not sure how your services will be covered. You have insurance but are unsure how to use your insurance for counseling. This blog will help you identify if using insurance for counseling is what is best for you.

Can I use my insurance for mental health counseling?

The answer depends on what you are hoping to work on when attending counseling sessions. When using insurance for mental health counseling, it is important to know that you will be required by your insurance company to be assigned a billable mental health diagnosis that serves as the basis for treatment. Insurance companies want to ensure that the services that they are paying for meet a medical necessity and will reduce the symptomology that you are experiencing.

What is medical necessity for mental health counseling?

In the world of clinical mental health care, medical necessity refers to the need for a specific treatment or service to address a diagnosed mental health condition and that the recommended treatment will improve or maintain the individual's condition. Insurance companies use medical necessity to determine whether they will cover the cost of services that are provided. The treatment provided by a mental health counselor must meet the following criteria:

1. Diagnosis and Treatment of a Mental Health Disorder: The individual, or identified client, must have a billable mental health diagnosis that aligns with the treatment plan and the things discussed in your sessions. Simply having a previous diagnosis but services not focused on that diagnosis does not count. Your counseling sessions must be centered around reducing the symptoms or discomfort that the diagnosis poses in your life.  

2. Individualized Treatment Plan: The treatment provided must be appropriate for the diagnosis and designed to alleviate symptoms or address underlying conditions. You cannot have a diagnosis of PTSD but have a treatment plan for increasing communication, as that plan would not be sufficient to reduce PTSD symptoms.

3. Evidence-Based Interventions: The interventions used in therapy should be supported by research or clinical evidence showing they are effective for the given condition. The goal of counseling is to improve the concerns that you came in for. The are numerous therapeutic interventions that have been proven to reduce a wide range of clinical symptoms and have positive clinical outcomes.

4. Frequency and Duration: The frequency and duration of your counseling sessions should be carefully planned to achieve your desired goals. For example, someone who is seeking treatment for PSTD or other acute stressors would not be recommended to have monthly sessions, as that frequency is often too spaced out to get good outcomes. Conversely, insurance will not continue to pay for general wellness sessions that continue after clinical goals are met and symptomology has decreased.

 At HOPE, our therapists work closely with you to assess your needs and determine your appropriate level of care. When it comes to seeking therapy, understanding your insurance coverage is key to knowing the options and limitations for the care you need. Many insurance plans cover mental health services, but the specifics can vary depending on your plan and provider.

Contact your insurance carrier and ask for your specific plan coverage for mental health. Understanding what your individual plan covers and the need for medically necessary services are important steps in accessing the care you need to support your mental health and well-being.

What if what I want to talk about in counseling does not meet a medical necessity?

If the things that you want to work on in counseling do not meet the criteria for medical necessity (e.g., services are more about personal growth, life stress, or improving communication skills rather than treating a diagnosable mental health condition you can proceed in one of the following ways:

1. Self-Pay (Private Pay)

Many counselors offer services outside of insurance that don’t require meeting the medical necessity criteria. Some advantages include: no need for a diagnosis or insurance approval, full privacy and confidentiality (no documentation is required to be shared with insurance companies), and flexibility to focus on goals like personal development, relationship improvement, or navigating life transitions.

2. Employer-Sponsored Programs/ Employee Assistance Programs (EAPs)

Many employers provide free, short-term counseling sessions for a range of issues like stress, relationships, and career challenges. These sessions are not used for more complex mental health conditions and focus on general wellness, so check with your HR department to see if an EAP is available to you.

3. Community and Non-Profit Resources

Community mental health centers and non-profit organizations often provide affordable or free counseling for a variety of life concerns.

4. Life Coaching or Support Groups

If your focus is on personal growth or achieving specific goals, consider asking your preferred counselor if they also provide life coaching. While not the same as clinical counseling and therapy, coaching focuses on actionable strategies and goal setting for general wellness and goal attainment. Support groups or workshops can also address topics like relationship skills, stress management, or personal growth that do not require much of a clinical focus.

Ultimately, deciding to begin counseling is a valuable tool for healing, growth and support, even if it isn’t covered by insurance. Many counselors and coaches offer free consultations. Take advantage of these offers to discuss your individual needs.

Our counselors would love to help you take the next step forward in your mental health journey. Click here to schedule a free 15-minute consultation and discuss your needs with a member of our team.