Does Insurance Cover Couples Therapy? And why is it so hard to get a straight answer?
If you’ve ever tried to figure out whether your health insurance will pay for couples therapy (billing code 90847), you may have gotten some very different answers.
Your insurance company might say, “Yes, we cover 90847.”
You search for therapists who accept your insurance on Psychology Today, but many will say, “I don’t take insurance for couples.”
Your friend might tell you, “Insurance never covers couples counseling.”
What the heck is actually true?
This is a controversial topic in the therapy world. As a seasoned expert in our field, I think more clarity would be good for everyone: clients, therapists, and the profession as a whole.
So … does insurance cover couples counseling?
Sometimes, yes. Couples therapists see the relationship as the client, and are experts in treating relationship problems. Insurance companies, on the other hand, use a medical model - not a relational model. For any covered benefit, including couples therapy, insurance companies ask three questions to determine medical necessity of the treatment:
Is there an identified patient with a mental health diagnosis?
Is that diagnosis causing functional impairment? That means, is the identified patient's sleep, mood, thoughts, behaviors, relationships, work, etc. negatively impacted because of the symptoms of this diagnosis?
Is the treatment reducing symptoms and improving functioning? For example, if someone's anxiety is being significantly worsened by ongoing relational conflict, and working with their partner is part of the treatment plan for reducing that anxiety and improving functioning, couples therapy may be medically necessary.
The billing code typically used for couples and family therapy is 90847. It is an established psychotherapy code for family/conjoint therapy with the patient present, and back when I contracted directly with insurance companies as an in-network therapist, 90847 was included in every insurance contract I had. Most of the time, I find that my couples clients meet criteria for medical necessity, both when I was in-network with insurance and now that I'm out-of-network (many of my clients receive out-of-network reimbursement for their sessions with me).
Then why do people claim that couples therapy isn't covered?
There are sometimes legitimate reasons for that. Sometimes, billing code 90847 is not a covered benefit under a particular insurance plan (a quick call to the customer service number on the back of your insurance card will give you that answer). Other times, the couples work does not meet criteria for medical necessity: if someone simply wants to communicate better with their spouse, have fewer arguments, improve their sex life, or strengthen an already-healthy relationship, there may not be enough justification for a diagnosis that insurance companies will accept. The goals are perfectly reasonable and worthwhile; they just aren't medically necessary according to insurance criteria.
But if a therapist is contracted with an insurance company, their contract includes 90847, and one of the partners qualifies for a diagnosis that would be improved by them participating in couples therapy, the therapist may not be able to simply decide, “I don't want to bill insurance for couples” and state that they're in-network but not for couples therapy. The exact requirements depend on the terms of the therapist's contract and the client's plan, but this is not necessarily a choice the therapist can make regardless of medical necessity.
In fact, Barbara Griswold, LMFT—the author of Navigating the Insurance Maze and one of my favorite resources for therapists trying to make sense of the insurance system—addresses this exact issue. Her guidance is that refusing to bill insurance for couples across the board, when the contract and client policy include couples/family codes, can be a contract violation, particularly if the therapist hasn't even assessed whether medical necessity exists.
So why do some couples therapists state that they don't accept insurance for couples?
There are two common explanations: reimbursement and lack of clarity about medical necessity. Couples and family sessions require specialty training and are often more complex because there are more people in the room. Yet insurance companies reimburse 90847 at a substantially lower rate than an individual therapy session. So couples and family therapists may spend more energy doing more complicated work and get paid less for it.
That financial reality can create a strong incentive for some therapists to avoid billing insurance for couples therapy and instead charge their standard private-pay rate, even when they have signed a contract agreeing to a lower reimbursement rate. There are also therapists who have signed an insurance contract but don't know what counts as medically necessary. They may fear submitting claims for couples therapy and having insurance deny those claims, which leaves the therapist with two bad options: seek payment from the client retroactively, or not get paid at all.
Rather than tackling the question of medical necessity head-on, some therapists avoid the issue entirely by assuming that couples therapy is never medically necessary. But that's simply not true. A better solution would be to push insurance companies to 1) adopt a fair financial structure for couples therapy and 2) make it abundantly clear what counts as medically necessary.
Our insurance system isn't simple, but simplicity and clarity are different things. I believe clarity would benefit our profession and the public. I'm not suggesting that every couple who wants therapy should automatically expect their insurance to pay for it. I'm also not suggesting that every therapist who doesn't bill insurance for couples is doing something wrong. What I am suggesting is that we should stop accepting the myth that “insurance doesn't cover couples therapy." The fact is, treating the couple can sometimes be the most appropriate, evidence-based, medically necessary treatment option, and insurance should pay for couples therapy when it meets the company's own criteria for medical necessity.
Most of my couples clients meet criteria for medical necessity
The average couples client waits seven years before getting help (credit to the Gottman Institute for this research). Imagine waiting seven years before seeking treatment for a medical issue—the waiting does additional harm. By the time a couple gets to my office, many are dealing with significant mental health symptoms that are affecting their daily lives, and those symptoms and relationship problems are often making each other worse. That's exactly the kind of situation in which treatment may meet insurance criteria for medical necessity.
Even with individual mental health diagnoses, the diagnosis belongs to a person in the context of a relationship, and the relationship is part of the clinical picture. In many cases, working with the couple is actually the most clinically appropriate way to treat the identified patient's symptoms. Sometimes the partner is part of the problem. Sometimes the partner is part of the solution. Either way, couples therapy is justifiable as medically necessary.
So what should you do if you're looking for couples therapy?
If you want to use your insurance for either in-network or out-of-network couples therapy, don't assume that “couples therapy isn't covered” is the end of the conversation. Ask some more specific questions.
Ask your insurance company: "Does my plan cover CPT code 90847 for a member who has a mental health diagnosis and whose treatment includes their partner?"
Also ask your insurance company, "What are my out-of-network mental health benefits?"
Ask in-network prospective therapists, "Is 90847 included in your contract, and if you determine that couples therapy is medically necessary for my treatment, would you bill my insurance?"
Ask out-of-network prospective therapists, "If you determine that couples therapy is medically necessary for my treatment, would you provide me with a Superbill for insurance reimbursement?"
Those questions can empower you to find a provider who can treat your relationship and collaborate with you in getting appropriately reimbursed for covered benefits under your insurance plan.
Comments