Understand your In-Network Coverage: Deductibles, Copays, and Co-Insurance

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 in-network providers to offer care at set rates, known as contracted rates. Depending on your benefits, you and your insurance company each pay a portion of that rate. The portion you pay is your payment responsibility.

Your copay, coinsurance, deductible, and out-of-pocket maximum can all affect what you owe. The exact amount depends on your specific insurance plan.

Understand Copays and Coinsurance

Depending on your plan, you pay for sessions through a copay or coinsurance.

Copay

A copay is a fixed amount you pay for a covered service. For example, if your plan has a $20 copay for mental health visits, you pay $20 per covered session, and your insurance company pays the remaining covered cost.

Coinsurance

Coinsurance is a percentage of the cost of a covered service that you are responsible for paying. For example, if your plan has 20% coinsurance, you pay 20% of the contracted rate, and 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.

Example: If your plan has a $1,000 deductible and a $20 copay per session, you 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, depends on your insurance plan. Depending on your benefits, you may be responsible for the full contracted rate for sessions until you meet your deductible.

What Happens After You Meet Your Deductible?

After you meet your deductible, your plan may begin covering a larger portion of your session costs. Depending on your benefits, you may then owe:

A copay, or fixed amount per session.
Coinsurance, or a percentage of the cost per session.
Another amount your insurance plan determines.

Meeting your deductible does not always mean your sessions are 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 pay for covered services during a plan year. Payments toward deductibles, copays, and coinsurance may count toward this maximum. Insurance premiums and services your plan does not cover generally do not count.

After you reach your out-of-pocket maximum, your plan may cover 100% of eligible in-network services for the rest of the plan year.

Contact your insurance company to confirm which expenses count toward your out-of-pocket maximum.

FAQs

What is the difference between a copay and coinsurance?

A copay is a fixed dollar amount per session. Coinsurance is a percentage of the session cost. Your plan uses one or the other, or sometimes coinsurance after you meet your deductible.

Do I have to meet my deductible before my insurance covers therapy?

It depends on your plan. Some plans require you to meet your deductible before coverage begins; others apply a copay or coinsurance from the start.

Does meeting my deductible mean my sessions are free?

Not necessarily. After you meet your deductible, you may still owe a copay, coinsurance, or another amount depending on your plan.

How do I know how much of my costs count toward my out-of-pocket maximum?

Contact your insurance company to confirm which expenses, such as your deductible, copay, and coinsurance payments, count toward your out-of-pocket maximum.