Navigating health insurance can feel overwhelming, even for people who use it regularly. Many clients come to their first session unsure of their copay, deductible, or what their insurance will cover. This is very common, and you are not alone.
As a licensed therapist, I do my best to guide clients through general insurance-related questions. However, insurance plans vary widely, and ultimately, clients are responsible for understanding their individual benefits.
This article is meant to serve as a general educational guide so you can feel more informed and prepared before seeing any medical or mental health provider.
Why Understanding Your Insurance Matters
Understanding your insurance benefits can help you:
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Avoid unexpected bills
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Make informed decisions about care
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Reduce anxiety around costs
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Advocate for yourself confidently
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Plan for ongoing treatment, if needed
Insurance confusion should never prevent someone from seeking care, but clarity can reduce stress and improve the overall experience.
Key Insurance Terms Explained
1. Copay
A copay is a fixed amount you pay at the time of your appointment.
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Example: $25 per therapy session
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Copays vary depending on your plan and provider type
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Some plans have $0 copays for certain services
*Copays are typically due at the time of service.
2. Deductible
Your deductible is the amount you must pay out-of-pocket before your insurance starts covering certain services.
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Example: A $1,500 deductible means you pay the first $1,500 of covered services
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Some plans waive deductibles for mental health services; others do not
*If your deductible has not been met, you may pay the full session fee until it is.
3. Coinsurance
After your deductible is met, some plans require coinsurance, which is a percentage of the cost.
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Example: Insurance pays 80%, you pay 20%
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This continues until you reach your out-of-pocket maximum
4. Out-of-Pocket Maximum
This is the most you’ll pay in a year for covered services.
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Once reached, insurance typically covers 100% of eligible services
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Copays, deductibles, and coinsurance usually count toward this amount
What Is an Explanation of Benefits (EOB)?
An Explanation of Benefits (EOB) is not a bill. It’s a statement from your insurance company explaining how a claim was processed.
Your EOB usually includes:
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Date of service
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Provider name
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Amount billed
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Amount of insurance allowed
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Amount of insurance paid
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Amount you may owe
*EOBs are typically available through your insurance portal or mailed to you.
How to Read an EOB Without the stress
When reviewing an EOB, focus on these key sections:
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“Amount Billed” – What the provider charged
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“Allowed Amount” – What insurance considers reasonable
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“Plan Paid” – What insurance covered
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“Patient Responsibility” – What you may owe
*If something doesn’t make sense, it’s okay to ask questions.
Common Reasons Clients Are Unsure About Their Costs
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Benefits changed at the start of the year
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Mental health coverage differs from medical coverage
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Deductibles reset annually
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Insurance portals are confusing
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Information is presented in complex language
*This confusion is understandable and very common.
Helpful Questions to Ask Your Insurance Company
Before starting care, consider calling the number on the back of your insurance card and asking:
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What is my copay or coinsurance for outpatient mental health services?
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Do I have a deductible? Has it been met?
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Is my provider considered in-network?
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Are there limits on the number of sessions per year?
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Do I need prior authorization?
*Write down the date, time, and name of the representative you speak with.
A Gentle Reminder About Responsibility & Support
While providers can offer general guidance, insurance companies are the final authority on coverage and costs. Clients are ultimately responsible for understanding their benefits and any balances due.
That said, you are allowed to ask questions. You deserve clarity. And you don’t need to feel embarrassed about not knowing. Insurance is multifaceted.
Final Empowerment
Your mental and emotional health matters. Understanding your insurance is one step toward accessing care with confidence rather than fear or uncertainty.
If you ever feel unsure, pause, ask questions, and seek clarification. Being informed is not being difficult; it’s being empowered to advocate for your care.
Disclaimer: This article is for educational purposes only and does not replace information provided directly by your insurance company. Coverage varies by plan.
Healthily,
Davia Knight, MA, LMHC-QS, CEO/Founder
Photo Credit: JMaples Media