Open Enrollment Is Underway: Your Therapy May Be Eligible for In-Network Coverage

Whether you are changing plans or renewing your current one, the start of a new plan year is a good time to check whether an out-of-network therapist can be covered at in-network rates.

Open enrollment for marketplace health insurance is beginning soon, and many employers also hold their own enrollment period around the same time. In the coming weeks, families will choose new plans, switch carriers, or let existing coverage renew. For most plans, deductibles reset to zero on January 1.

For anyone in therapy, or paying a therapist who does not accept insurance, this is an important time to pay attention. Many people assume that if their therapist is out of network, they must pay entirely out of pocket, especially when a plan has no out-of-network benefits. That assumption can cost families a lot of money each year, and it is often not the full picture.

The Challenge Many Families Face

Many therapists that our community relies on do not take insurance. They understand our families, our culture, and our values, and once you have found the right person, starting over with someone new is not always realistic.

At the same time, an insurance directory may list many in-network providers. But when people begin calling, the situation often looks different: some are not taking new patients, some never return calls, some are too far away, and some do not have the training needed for a particular situation. A list of names is not the same as real access to care.

Finding the right fit matters just as much. People enter therapy with specific concerns, and many therapists specialize in or have advanced training in those very issues. In medical care, you need a doctor who can properly treat your condition, and federal and state mental health parity laws generally require plans to treat mental health care no more restrictively than medical care. Network adequacy rules generally apply to mental health providers as well.

If your therapist specializes in what you are dealing with, speaks your language, or can see you when you are actually available, those are meaningful reasons to stay with them, and they can support a request for coverage.

If you are in therapy, trust your therapist, and are making progress, you do not have to stop seeing them. Before assuming you are stuck paying out of pocket, find out whether your therapy can be covered through your insurance.

Gap Exceptions and Single Case Agreements

Health plans are generally expected, and in many cases required by state or federal rules, to give members reasonable access to care through their network. When the network cannot provide an appropriate, available provider, a member may be able to request a network gap exception or a single case agreement (SCA). The two terms sound similar, but they work differently.

A single case agreement is an arrangement between the insurance company and your therapist. The insurer negotiates a rate with the therapist, and the therapist agrees to accept it for your sessions for a set period of time. In effect, the therapist is treated like an in-network provider for you, and you pay your in-network copay, deductible, and coinsurance.

A network gap exception is approved for you, the member. The plan agrees to cover your out-of-network therapist at your in-network benefit level. You continue seeing your therapist as usual: you pay them, get receipts, submit them to the insurance company, and reimbursement is typically sent directly to you. Your therapist usually does not need to sign a contract or negotiate a rate with the insurer.

Even Without Out-of-Network Benefits, You May Still Qualify

This is the point many people miss. These requests usually depend on whether the plan’s network can actually meet your needs, not on whether your plan includes out-of-network benefits.

• If your plan has no out-of-network benefits (common with EPO and HMO plans), you may still qualify. An approved exception may be the only way the plan will cover your therapist at all.
• If your plan does have out-of-network benefits (common with PPO and POS plans), you may still benefit, often significantly.

Here is why. When you submit therapy bills yourself under out-of-network benefits, you typically:

• Receive nothing back until you meet the out-of-network deductible, which is usually separate and often high.
• Get reimbursed only a percentage of the plan’s “allowed amount,” which is usually based on a lower rate and may be far below what your therapist charges.

With an approved gap exception or single case agreement, therapy is treated as in-network instead. That usually means:

• Your sessions count toward your in-network deductible, which is usually much lower.
• Depending on the plan, reimbursement may be based on a higher approved rate.
• The plan pays its in-network share, which is usually higher than its out-of-network share.

For someone in weekly therapy, that difference can add up quickly over a year. Keep in mind that with a gap exception, you may still owe the difference between your therapist’s fee and the amount the plan approves.

Why Acting Now Matters

• For most plans, deductibles reset on January 1. Getting a request in early means sessions in the new year can count toward the correct deductible from the start.
• A new plan means new rules. If you are changing plans, your new plan has its own network, and any arrangement with your old plan generally does not carry over.
• Renewing? Check anyway. Plans can change networks and benefits from year to year. Even if you keep the same coverage, it is worth reviewing your position for the coming year.
• Approvals take time. These requests usually require documentation and follow-up with the plan. Starting early is better than waiting until later in the year.

Who Should Reach Out

If you have private insurance, whether through an employer or a plan you bought yourself, or a marketplace plan, and you see a therapist who does not take your insurance, it is worth finding out whether your therapy could be covered at in-network rates.

Therapists in private practice who do not participate with insurance can also share this information with their clients. Clients may be able to continue care without bearing the full cost alone.

Open Enrollment Window

• New Jersey (Get Covered New Jersey): Enrollment opens in early November and runs through late January. Enroll by the end of December for coverage beginning on January 1.
• New York (NY State of Health): Enrollment opens in early November and runs through late January.
• Other states (HealthCare.gov): Enrollment opens in early November and runs through mid-January. Enroll by mid-December for coverage beginning on January 1.
• Employer plans: Your employer sets its own window. Watch for emails from HR.

Dates can change; confirm with your state’s official marketplace or your employer.

How Access to Coverage Helps

Access to Coverage is an insurance advocacy service based in Lakewood, NJ, working with clients across the United States. The team helps clients request network gap exceptions and single case agreements, and advocates through the appeals process when a plan says no, so families can keep seeing the therapists they already trust. Over the years, the service has helped hundreds of families with therapy coverage.

The company pushes for gap exceptions whenever possible. They are usually easier for everyone: the therapist keeps their usual practice and fees, and the client gets reimbursed at in-network levels. Many private and commercial insurance plans allow this.

• We handle the legwork. Paperwork, phone calls, and follow-up with the insurance company, so you can focus on care.
• Secure and HIPAA-compliant. Information is handled through secure systems using current technology.
• Simple, transparent pricing. No approval fee unless your insurance company issues a written approval. There is a $150 non-refundable application fee to open a case. There are no percentage-based fees and no hidden charges. The approval fee covers the approved authorization period; renewals and optional billing services are priced separately.
• Appeals included at no extra charge. If a request is denied, the appeals process is pursued, and in some cases an independent external appeal is also pursued. There is no additional fee for appeals.
• Optional billing services. Once approved, clients or therapists who need help submitting bills for reimbursement can use an optional billing service. Administrative support is provided for claims submission and follow-up.

We are here to help people get covered and advocate strongly for every client. If you have private or commercial health insurance, whether through your job, a plan you bought yourself, or the marketplace, reach out with any questions. We will be glad to help you try to get the coverage you, your spouse, or your family members need.

Questions? Reach out anytime. We are here to help. Call or text (732) 475-2111.

Have a question? Find out if your therapy can be covered.
Reach out with any questions. Contact Access to Coverage to see if your therapy can be covered at in-network rates.

Call or text: (732) 475-2111
WhatsApp: Message us on WhatsApp
Email: [email protected] (Email us anytime. We respond quickly.)
Online: www.accesstocoverage.com

Disclaimer: This article is for general informational purposes only and is not legal, financial, tax, or medical advice. Reading it does not create a client relationship with Access to Coverage.

Access to Coverage is an administrative insurance advocacy service. It is not a law firm, does not provide legal representation, and is not a therapy, medical, or mental health provider. It is not an insurance company or broker and is not affiliated with, endorsed by, or acting on behalf of any insurance carrier, employer, or government marketplace.

Coverage, network rules, deductibles, reimbursement rates, and eligibility vary by plan, employer, and state. Whether a gap exception, single case agreement, or appeal is approved is decided solely by the insurance plan or the reviewing authority. Approval is not guaranteed, and past results do not predict future outcomes. Even with an approval, you may be responsible for deductibles, copays, coinsurance, and any amount above what the plan allows.

Fees: a $150 non-refundable application fee applies to each request. The flat approval fee is charged only if the insurance company issues a written approval. Renewals and optional billing services are priced separately. Full terms are provided in writing before any engagement.

Enrollment dates are based on publicly announced information and may change; confirm with your employer or your state’s official marketplace. Your information is handled under applicable privacy laws, including HIPAA. Sponsored content.