A simple guide to picking health insurance with out-of-network coverage, plus easy explanations of common insurance terms you need to know.
This year, we are shopping around for a new insurance plan and I wanted to go over how to find an insurance plan with out-of-network coverage.
This is really beneficial for anyone with complicated medical needs. Many times it’s difficult to get in for a psychological evaluation quickly using an in-network provider, and other services are similar.
Generally, you see longer wait times to get into medical services with in-network providers. Those providers have higher caseloads.
When you think you might need to use multiple out of network providers- or even just one- it is really helpful to have this coverage.
Note that I’m not an insurance specialist, nor do I claim to know a whole lot about insurance… I just know what I’ve had to learn for choosing coverage for my own family. PLEASE consult with someone who knows more than I do if you have any questions or concerns, or just to fact check me! I’m hoping the information that I provide can just be general guidance to take some of the scary out of this whole process.
Please make an appointment through the patient portal or call 443-300-6094 if you’re interested in pursuing therapy in Howard County, Maryland through Happy Honeysuckle Healing Center. If you have a psychiatric or medical emergency, please contact 911 or go to your nearest emergency room.
This blog is for educational purposes only. This information is best case scenario, at least within the scope of my knowledge and experience at the time I write the post. Not only does everyone have different approaches to parenting and life- and my way may not be your cup of tea, but also- I am not perfect, nor do I want anyone to imagine that I am. Despite being a therapist and having a whole host of really cool techniques for all the mental health related things, I am constantly learning and trying to do better.
I’m hoping that this blog can help you. When we share what works for us, we can help others develop their own toolkit for improving their mental health. As an affiliate with Amazon and other affiliate networks, I may earn from qualifying purchases made with product links on this site. If you’re a current client of this practice, you have access to therapist-created resources free of charge.
I’m going to use Carefirst for my example (our BCBS provider in Maryland) to show how to find the right plan. There aren’t a lot of PPO options in my area if you don’t have an employer subsidizing your plan. Also, we don’t receive any subsidies (which I believe will be going away for 2026 regardless) so this is the full price of the insurance for 5 people.
Our plan options suck. Many people have far better benefits than this. But I don’t have a good plan to show as an example.
First, IDENTIFY what plans are offered.
These are the 2026 plans offered by Carefirst in my area. If the plan says HMO, it will NOT offer coverage for out of network providers.
Unfortunately, this main snapshot of the plans doesn’t explain the out of network coverage.
Click GET A QUOTE and enter your zip code. Enter your family info. I’m entering 5 people.
The price for insurance for each person is based on age, so you’ll notice that the oldest person in the family is likely more expensive than the youngest one. I believe gender plays a role as well, but I’m not sure because we are a family with only one female.
Once you input all of this, you will get a bunch of options for different plans.
You should filter for only PPOs. Those are the only kind of plans that allow out of network provider reimbursement.
You’ll see a few different options that you can then decide between.
Deductibles vs. Out of Pocket Max
Usually the plans have different deductibles for out of network providers than for in network. A deductible is the amount you pay before the insurance company is willing to pay ANY part of the cost of your healthcare. You pay 100% of this before insurance kicks in.
Your out of pocket max is the MAXIMUM AMOUNT OF MONEY that you will need to pay with that plan. Most people stay under this limit, but for people with a lot of medical needs, you may meet it. Once you meet that number, all your healthcare for the remainder of the policy year is free. Note: there may be some exceptions depending on your plan.
For example, I had two wrist surgeries for our policy year + ended up meeting our out of pocket max. Now I pay a $0 co-pay for everything for the remainder of the policy year (In most cases this would be the end of December, but our plan renews December 1st).
Gold Plan with Out of Network Benefits: $2,570.19/month
This plan is the gold plan.
This plan has a $2000 out of network deductible for individuals. The family one matters to in our case, but we’re going to ignore that piece of the equation.
After 10 instances of the $200 service, I would meet this deductible.*
During that time, I would be submitting the superbills and paying the provider 100% of their rate.
Once I met my deductible, I would continue to pay the $200 fee to the provider and submit the superbills. My insurance company would then pay me back 20% of the allowed benefit. After every submitted superbill for one session, I would get $40 back.
Let’s say that I see only one provider out of network and I see them weekly. Assuming the provider isn’t available every week of the year- nor am I- we are looking at maybe 48 sessions per year.
I would hit my out of network max at $17,000. The $9600 cost for one provider for 48 weeks would NOT get me to that point.
- Cost of 48 therapy sessions: $9,600
- Reimbursement amount from insurance: $1,520
- Total cost of therapy: $8,080
I am not certain if I would hit my out of pocket max though for in-network… I’m a little unclear on if the out of network services help you hit that or if they only count towards your out of network out of pocket max.
That all said, I would have very low copays for in-network providers compared to my current plan. Many lower cost plans have copays of up to $100/session for in network specialists. This includes the copay for acupuncture, physical therapy, the allergist, etc. Mental health seems to be separate from specialist care so that was $40/session, as was seeing the PCP for a sick visit.
*The tricky part is that this particular policy states “allowed benefit.”
Insurance companies have decided how much they think a service is worth. Therapy in particular is a little tricky because they don’t let us nickel and dime like other professions. They tend to set our rates pretty low. Some of this depends on the location. It has absolutely nothing to do with your therapist’s skills or expertise.
For this plan, I don’t see any mention of what the allowed benefit is for the services. I’m not sure where you are supposed to find that information. Is it a surprise? That sounds about right for insurance in America.
A ChatGPT request stated that insurance companies don’t publish a master list of this…. you will see the amount on your Explanation of Benefits form. It’s also seen on in-network contracts- ie. when a provider contracts with an insurance company, the insurance company tells them what they’ll get paid. So- AND I QUOTE CHATGPT- “The only reliable place you see them for sure is after a claim is processed- on your EOB.”
So if the insurance company decides that therapists should only earn $120 a session, they will only reimburse you for 40% of $120 after your deductible is met or $120 after you meet your out-of-pocket max.
This is a reminder that our insurance options are BAD. This is why owning a small business (or working for a small business) is problematic. With most of our plan options, we’re looking at spending $30,840 if we buy the plan and don’t use it… but potentially WAY more if we use it. I think we calculated that the cost of the insurance plan and the healthcare costs us about $50,000+ per year. If more than one person uses the out of network benefits consistently and we hit that out of pocket max, we could be paying up to $64,840 in healthcare costs with the plan above, including the cost of our plan for the year. This is more than we- and most people- likely pay for their mortgage each year.
This means that if we can find a job that pays us $50,000 less per year, but offers much better/subsidized insurance, we’d likely be better off changing where we work. The unfortunate part- and the part that’s difficult to account for- is that we both like our jobs. I’ve worked jobs with great pay and benefits, but the stress wasn’t worth it.
GOOD Out of Network Benefits
If you have the option of a plan with a deductible under $3000 for out of network care and with 50-75% covered by insurance, this can be SO helpful. It opens you up to see more providers, often meaning shorter wait times to see a provider and the option to see providers who are very niche. For example, in our area, I haven’t found in many network providers who specialize in: neurodivergent affirming care, speech and language, POTS assessment, ADHD/Autism assessments (I personally like to refer clients to providers who are competent/specialized in assessing for both together as they can mask each other a bit), etc.
I have a family member who had a plan with $40 copays for out of network specialists which is amazing, although I’m unsure of the plan cost or the deductible.
I don’t have a good plan to show you so it’s difficult to do any decent math here, but I’ll give you a made up example. I’m going to ignore out of pocket max because people rarely meet that number.
- $1000 Out of Network Deductible, 60% covered by insurance after deductible.
- After 5 sessions, your deductible would be met.
- At that point, when that person sees ANY out of network provider, the insurance company will pay 60% of the cost. If they accept the $200 fee as the allowed benefit, they would reimburse $120 of a $200 session, effectively giving you a copay of $80/session.
There are better and worse plans that this hypothetical scenario… and I don’t know how much the plan above would cost either.
When can you change your health insurance plan?
Generally open enrollment– the time period during which you can change your health insurance plan- which I believe always runs from Nov 15-January 15 each year. Private companies may have a different period for open enrollment (frequently this seems to be a December 1st turnover for the insurance calendar year).
If you have a life event- ie. marriage, birth of a child, etc., you may be able to change plans at other times.
Other Considerations for Health Insurance Plan Selection
For mental health, you have two other considerations for selecting a healthcare plan.
The first is psychiatric hospitalization. If someone in your family may be at risk for psychiatric hospitalization, you want to look at the coverage of the plan.
In this example plan, you’d have a $450 copay after the deductible for both inpatient mental health or substance abuse care. This amount can be ASTRONOMICALLY more expensive with some plans… thousands of dollars. If you think there’s even a remote chance that someone in your family may need this level of care, consider your plan options VERY carefully. I’ve seen people absolutely devastated by inpatient costs.
The other consideration is medication. Generally, insurance plans will cover the generic medications. Some of the newer medications are brand name only, however. This seems to be particularly relevant for newer meds that are easier for young kids to take for ADHD. If your child has a history of medication refusal or won’t swallow pills, you might want to ensure your coverage includes coverage for brand name medication. It simply gives you more options.
The other piece of this is that generic medication is made by multiple different manufacturers and they are not all equivalent. One manufacturers version of the generic medication may work really well for you, but another may not.
One solution to this is for your prescriber to request that particular generic manufacturer on the prescription. This prevents your symptoms from yo-yo’ing whenever the manufacturer changes. The one downside to this is that you need to plan ahead for refills because your pharmacy may need to order the medication.
Tip: when you look at your medication bottle, you can see who the manufacturer is.
Generic medications do not undergo and repeat the clinical trials that the brand names completed. They just need to be the bioequivalence of the name brand medication… they are tested to ensure they meet the guidelines for bioequivalence. Generally, for most people, this will be fine.
But if you’re struggling with mixed results for medication efficacy month to month, it’s something to look at. In this case, buying the preferred name makes sense. Honestly, I like the idea of starting with a name brand medication regardless to determine if it’s effective for the individual, then downgrading to the generic if it makes sense. Many psychiatric drugs just take so long to be effective that it’s a frustrating process without adding in other considerations.
Final Thoughts
This is obviously quite complicated to evaluate.
There are a lot of factors to consider- for example, buying a more expensive insurance plan through an employer is PRE TAX dollars. You may save money on taxes by reducing your taxable income. Some people can itemize medical expenses separately, but there are usually guidelines to whether or not it’s worth itemizing those.
I have a family member who has changed plans a few times and it can cause a SERIOUS interruption to their health as some plans will cover their medication and some won’t. Changing medication when you’re barely stable is MASSIVELY problematic. It’s simply NOT worth saving $100/month on your health insurance if you’re in pain, have additional visits to the ER/doctor/specialist, and can’t function during that time.
There are also some insurance networks with more providers- and some insurance networks scare away providers due to how they treat or pay the providers.
Another consideration is how many providers are close to you- if you need a specialty service, can you find someone close who is in network? Or will you need to commute an hour roundtrip to get to a physical therapist twice per week? If you need to commute, will you lose work time? Do you have paid leave to cover that or will you lose income traveling?
For those with low healthcare costs, eh. You can opt to try to save money on health insurance by using a low level plan. It might be worth it for you.
But many neurodivergent people have pretty substantial healthcare needs.
I hope someday I can take this post down because we will all have access to affordable healthcare for our families and we won’t need to navigate this complicated system. But until then, I hope this is helpful. Let me know if you see someone that’s incorrect, or that changes. I’ll try to keep this updated.
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