Out of network means your therapist doesn’t have a contract with your insurance company. This changes how you pay: instead of your insurance handling the bill directly, you pay your therapist the full session fee upfront and then submit a claim to your insurance for partial reimbursement. Whether you get any money back, and how much, depends entirely on the details of your specific plan.
How Out-of-Network Billing Works
When a therapist is in network, they’ve agreed to accept a negotiated rate from your insurance company, and billing happens between their office and your insurer. You pay a copay or coinsurance at each session, and that’s it. Out of network flips that process. Your therapist sets their own rate, you pay it at the time of service, and then you’re responsible for getting reimbursed by filing a claim yourself.
To file that claim, your therapist gives you a document called a superbill. This isn’t a regular receipt. It includes your therapist’s license information and provider ID number, a diagnosis code (like one for anxiety or depression), a procedure code that tells the insurer what type of session you had (individual therapy, couples therapy, an initial assessment), the date of service, the fee charged, and proof of payment. You submit this to your insurance company, usually by uploading it through their member portal or mailing it in. Processing typically takes a few weeks.
What You’ll Actually Pay
The math behind out-of-network reimbursement has a few layers, and each one can shrink the amount you get back.
First, there’s your out-of-network deductible. This is the amount you must spend before your insurance reimburses anything at all. Most PPO plans have separate deductibles for in-network and out-of-network care, and the out-of-network deductible is almost always higher. Until you hit that number, you’re paying 100% of every session out of pocket.
Once you’ve met the deductible, your insurance reimburses a percentage of what they consider the “usual and customary rate” for therapy in your geographic area, not necessarily a percentage of what your therapist actually charges. This is a critical distinction. If your therapist charges $250 per session but your insurer determines the usual and customary rate in your area is $175, the reimbursement percentage applies to that $175 figure. Common reimbursement rates for out-of-network care on PPO plans range from 50% to 80%, depending on the plan. So in that scenario, with a 60% reimbursement rate, you’d get back about $105 per session and be responsible for the remaining $145.
If your plan is an HMO or an EPO, you likely have no out-of-network benefits at all, meaning you’d pay the full cost with zero reimbursement. PPO and POS plans are the ones most likely to offer some level of out-of-network coverage.
Why Some People Choose Out-of-Network Anyway
Given the higher costs, it’s fair to wonder why anyone would go this route. The reasons are practical.
In-network therapists are often restricted by insurance guidelines on how often they can see you and for how long. Some plans limit in-network therapy to once a week for a maximum of 8 to 10 sessions. If you’re in crisis or dealing with something that needs more intensive support, that ceiling can be a real problem. Out-of-network therapists aren’t bound by those limits. They can offer longer sessions, more frequent appointments, or open-ended treatment without needing approval from an insurer.
Specialization is another factor. Many out-of-network therapists run niche practices with deep expertise in specific conditions. If you need help with something like an eating disorder, trauma, or substance use, an out-of-network specialist may offer treatment approaches that in-network providers simply don’t. For example, in-network substance abuse programs often follow a strict abstinence-only model, while specialized out-of-network clinicians may offer harm reduction or moderated approaches tailored to your situation.
Privacy also plays a role. When you use in-network benefits, your therapist is required to share a diagnosis code and session details with the insurance company. If you’re on a parent’s plan, that parent could potentially see claims activity. If your employer self-insures (meaning the company itself funds the health plan rather than buying coverage from an insurer), there are circumstances where utilization data could be visible internally. Paying out of network, or fully out of pocket, keeps your therapy off those records.
How to Check Your Out-of-Network Benefits
Before booking with an out-of-network therapist, call the member services number on the back of your insurance card. Have a few specific questions ready, because the general answer of “yes, you have out-of-network benefits” doesn’t tell you enough to plan your budget.
- Do I have out-of-network coverage for mental health services? This is the baseline question. If the answer is no, the rest doesn’t matter.
- What is my out-of-network deductible, and how much have I met so far this year? Your plan year might reset in January or on another date, so confirm the policy year as well.
- What is the usual and customary rate for my area? The representative may ask you for a procedure code. For a standard individual therapy session, the codes are 90834 (a 45-minute session) or 90837 (a 60-minute session). For an initial assessment, it’s 90791.
- What percentage does the plan reimburse after the deductible? This is your coinsurance rate for out-of-network services.
- Is there a session limit per year? Some plans cap the number of reimbursable sessions annually.
- Does my plan require pre-authorization or a referral for psychotherapy? Some plans require a primary care referral before they’ll process out-of-network mental health claims.
With those answers, you can calculate your real per-session cost. Multiply the usual and customary rate by your reimbursement percentage to find what you’ll get back, then subtract that from your therapist’s actual fee. That’s your true out-of-pocket cost per session after the deductible is met.
Good Faith Estimates for Self-Pay Patients
If your plan doesn’t cover out-of-network care, or you decide to skip insurance entirely and pay out of pocket, you have a right under the No Surprises Act to receive a good faith estimate of expected charges before you start treatment. Your therapist is required to provide this for scheduled services. If the final bill ends up being significantly higher than the estimate, you can dispute it through a federal patient-provider resolution process. This protection applies to anyone who is uninsured or choosing to self-pay.
Making the Cost Work
If you have a health savings account (HSA) or flexible spending account (FSA), therapy paid out of pocket or out of network is generally an eligible expense. That means you can use pre-tax dollars to cover your portion, which effectively reduces the cost by whatever your tax rate is.
Some out-of-network therapists offer sliding scale fees based on income, or will submit superbills to your insurance on your behalf so you don’t have to manage the paperwork yourself. It’s worth asking about both before your first session. A therapist who regularly works with out-of-network clients will already have a system for this and can often tell you, based on your plan details, roughly what to expect in reimbursement.