Use this article to understand how your in-network insurance benefits affect what you may pay for sessions, including copays, coinsurance, deductibles, and out-of-pocket maximums.
How In-Network Insurance Costs Work
Insurance companies contract with providers in their networks to offer care at set rates, known as contracted rates.
Depending on your insurance benefits, you and your insurance company may each pay a portion of the contracted rate. The amount you are responsible for paying is your payment responsibility.
Your payment responsibility may be affected by your:
- Copay.
- Coinsurance.
- Deductible.
- Out-of-pocket maximum.
The amount you owe depends on the specific benefits of your insurance plan.
Understand Copays and Coinsurance
Depending on your insurance plan, you may pay for sessions through a copay or coinsurance.
Copay
A copay is a fixed amount you pay for a covered healthcare service.
For example, if your insurance plan has a $20 copay for mental health visits, you may pay $20 for each covered session while your insurance company pays the remaining covered cost.
Coinsurance
Coinsurance is a percentage of the cost of a covered healthcare service that you are responsible for paying.
For example, if your insurance plan has 20% coinsurance, you may be responsible for paying 20% of the contracted rate while your insurance company pays the remaining covered amount.
Depending on your plan, coinsurance may apply only after you meet your deductible.
Understand Your Deductible
Your deductible is the total amount you must pay each year before your insurance begins covering costs.
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Example:
If your plan has a $1,000 deductible and a $20 copay per session, you’ll pay $20 per visit until your total medical spending reaches $1,000. After that, your cost drops to $0 per session.
Your deductible amount and how it applies to mental health services depend on your insurance plan.
Depending on your benefits, you may be responsible for paying the full contracted rate for sessions until you meet your deductible.
What Happens After You Meet Your Deductible?
After you meet your deductible, your insurance plan may begin covering a larger portion of your session costs.
Depending on your benefits, you may then be responsible for:
- A copay, or fixed amount for each session.
- Coinsurance, or a percentage of the cost of each session.
- Another amount determined by your insurance plan.
Meeting your deductible does not always mean your sessions will be fully covered.
Contact your insurance company using the phone number on the back of your insurance card to confirm how meeting your deductible affects your mental health benefits.
Understand Your Out-of-Pocket Maximum
Your out-of-pocket maximum is the most you may be required to pay for covered healthcare services during a plan year.
Payments toward deductibles, copays, and coinsurance may count toward your out-of-pocket maximum. Insurance premiums and services your plan does not cover generally do not count toward this amount.
After you reach your out-of-pocket maximum, your insurance plan may cover 100% of eligible in-network services for the remainder of the plan year.
Contact your insurance company to confirm which expenses count toward your out-of-pocket maximum.
How Alma Tracks Changes to Your Deductible
Alma runs monthly eligibility checks when your provider uses the Alma calendar to schedule sessions. If your deductible changes, resets, or you shift to a copay or coinsurance, we will automatically update your cost.
When you are within $200 of meeting your deductible, Alma will email you and begin billing as if your deductible is already met. This helps prevent overcharging if your remaining balance is smaller than a full session cost.
If we later learn that you owe more than the estimate, Alma will send an updated invoice for the difference.
Billing and Invoices
After each session, your provider submits a claim to your insurance company. You’ll then receive an invoice based on your payment type:
- Copay: You will receive an invoice soon after your session.
- Coinsurance: You will receive an invoice after your insurance company processes the claim, which typically takes 45–60 days.
Sometimes your final invoice differs from your original eligibility estimate. This happens when:
- You meet your deductible between the eligibility check and the claim being processed.
- Your session details change (for example, from a 45-minute to a 60-minute appointment, which has a different contracted rate).
| Note: Your insurance company decides the final amount you owe, and Alma adjusts your invoice to match that determination. |
When Will My Cost Estimate Change After Meeting My Deductible?
You can view your most up-to-date cost estimate in the Alma Client Portal.
For more information, see View Your Cost Estimate in The Alma Portal.
What if My Deductible or Cost Estimate Looks Incorrect?
If you believe you have met your deductible but your cost estimate has not changed, contact your insurance company to confirm:
- Your current deductible status.
- Whether your deductible applies to mental health services.
- What you should expect to pay after meeting your deductible.
If your insurance company provides information that differs from the information shown in Alma, you can request a review. For next steps, see Request a Review of Your Insurance Eligibility or Cost Estimate.
What Happens After a Claim Is Processed?
Your insurance company makes the final determination about how much you owe for a session.
If the final amount differs from your original cost estimate, Alma will adjust your invoice based on the processed claim.
For more information, see Claim Process: How Billing Works at Alma.