Why Don’t Therapists Take Insurance? (And How to See One Anyway)
You finally find a therapist you actually want to talk to.
Their website feels like they get it. Their approach makes sense. You read their bio and think, Okay, this person might actually understand me.
Then you get to the fees page:
Out of network.
Cool.
So... now what?
One thing before we get into it: The practice I currently work with is in network with Aetna. So if you have Aetna, you may be able to use your in-network benefits to work with me. Reach out and we can check your coverage.
If you have another insurance plan, or you're just trying to understand why so many therapists are out of network, keep reading. It's worth knowing what your options actually are before the words “out of network” make the decision for you.
If you're looking for a therapist in California, there's another thing I really want you to know:
Out of network does not necessarily mean your insurance pays nothing.
If your plan has out-of-network mental health benefits, you may be able to get reimbursed for part of the cost of therapy.
But first, let's talk about why some therapists don't take insurance in the first place.
Why Don't Some Therapists Take Insurance?
1. If You Use Insurance for Therapy, a Diagnosis Code Is Required
This is something many people don't realize before starting therapy.
If you use health insurance to pay for therapy, a diagnosis code is required on the insurance claim.
That applies whether your therapist is in network or you're seeing an out-of-network therapist and submitting a claim for reimbursement.
Sometimes that's completely appropriate.
If you're seeking treatment for depression, PTSD, OCD, an anxiety disorder, or another mental health condition, a diagnosis may accurately describe what you're experiencing.
But not everyone comes to therapy because they have a mental health disorder.
Maybe you're trying to understand why you become a completely different person around your family.
Maybe you're exhausted from always being the person everyone depends on.
Maybe you're figuring out which parts of your life you actually chose and which came from family or cultural expectations.
Maybe you're working on identity, relationships, boundaries, people-pleasing, or figuring out who you are underneath who you learned you were supposed to be.
Those are real reasons to go to therapy.
But wanting help understanding yourself doesn't automatically mean you have a mental health disorder.
Insurance also has rules about what it considers medically necessary treatment. Therapy can be meaningful and useful even when what you want to work on doesn't fit neatly into that framework.
Depending on your plan and circumstances, an insurance company may require documentation to support why treatment is medically necessary or whether continued treatment meets its requirements.
That's one reason some therapists choose to work outside insurance. It gives you and your therapist more room to decide together what you want to work on and how long the work makes sense.
And there's one important distinction here:
Out of network does not mean outside of insurance.
If you submit an out-of-network claim or superbill for reimbursement, you're still using insurance. A diagnosis code is required on that claim.
If you pay privately and don't submit claims for reimbursement, no diagnosis is being sent to your insurance company as part of a claim.
2. Lower Reimbursement Can Mean Larger Caseloads
This is where insurance reimbursement can affect you in a way that's easy to miss.
When an insurance company pays a therapist substantially less per session, one way to make the practice financially sustainable is to see more clients.
Here's a simple example.
Imagine a therapist charges $200 per session, but an insurance contract reimburses $120 per session.
At 20 sessions per week:
20 private-pay sessions at $200 = $4,000
To bring in the same amount at $120 per session, the therapist would need to see about:
33 clients per week.
That's 13 additional people every week.
The exact numbers aren't the point. Insurance reimbursement varies widely by plan, location, contract, and provider.
The caseload is the point.
Therapy isn't only the 50 minutes you spend sitting across from someone.
A therapist may also spend time thinking about your treatment, reviewing what came up in previous sessions, writing notes, researching something relevant to your care, consulting with colleagues, coordinating care when appropriate, and planning where the work might go next.
Now imagine doing that for 20 people.
Then imagine doing it for 33.
That's one reason some therapists choose not to accept insurance. A smaller caseload can create more room around each client's treatment.
More room to remember the details.
More room to think about what happened in your last session before you walk through the door.
More room to notice patterns across weeks instead of treating every appointment like an isolated 50 minutes.
More room to research, consult, prepare, and think carefully about where your treatment is going.
And more room for your therapist to actually be mentally present when you're sitting across from them.
That doesn't mean a therapist who accepts insurance isn't present or doesn't provide excellent care. Many do.
It means that the financial structure of insurance can create pressure to see more clients, and some therapists choose a different model because they want to protect the amount of time and attention they can give to each person's treatment.
For the client, that's the part that matters.
3. There's Also a Lot of Work You Never See
Insurance comes with paperwork.
Claims get rejected. Documentation gets requested. Payments get delayed. Claims have to be corrected or resubmitted.
A big medical practice may have a billing department to handle all of that.
A solo therapist?
Often, the therapist is the billing department.
For some therapists, not taking insurance means spending less time dealing with insurance companies and more time doing therapy.
What If I Don't Want a Diagnosis Submitted to Insurance?
If what you just read about diagnosis codes gave you pause, that's a real thing to weigh.
Paying privately without submitting claims means you're not sending a diagnosis to your insurance company for reimbursement. You can also ask any therapist you're considering directly: “If I use my insurance benefits, what diagnosis would you be submitting and why?”
You deserve enough information to decide for yourself whether using your insurance benefits makes sense for you.
But How Am I Supposed to Afford an Out-of-Network Therapist?
This is probably the question you actually came here to answer.
You find a therapist you like.
Their fee is $200 per session.
You immediately calculate $800 a month and close the tab.
Before you do that, check whether your insurance plan has out-of-network mental health benefits.
Because the therapist's listed fee and what therapy ultimately costs you may be two different numbers.
Here's One Example
Let's say your therapist charges $200 per session.
Your insurance has out-of-network benefits, you've met your deductible, and your plan reimburses 70% of its allowed amount.
Let's pretend your insurer's allowed amount is $180.
70% of $180 = $126
You pay your therapist $200.
Your insurance reimburses you $126.
Your effective cost: $74
That's it. That's the math I want you to understand.
A therapist who charges $200 might ultimately cost you $200.
Or $150.
Or $100.
Or $74.
It depends on your plan.
There's one catch that's important: your deductible matters.
If you haven't met your out-of-network deductible yet, you may initially be paying the full fee while eligible expenses accumulate toward it.
And when an insurer tells you it reimburses “70%,” ask whether that's 70% of the therapist's fee or 70% of the insurance company's allowed amount.
That one question can save you a lot of confusion.
What If I Have an HMO or Medi-Cal?
Not every insurance plan includes out-of-network benefits.
PPO plans are more likely to include them. HMO plans generally don't provide routine out-of-network coverage except in specific circumstances. Medi-Cal also generally works through its provider networks rather than reimbursing you for choosing a private out-of-network therapist.
If you don't have out-of-network benefits, that doesn't mean you're out of options.
An in-network therapist, a therapist with a reduced-fee or sliding-scale spot, or another lower-cost therapy option may be a more realistic path.
The important thing is to check your actual plan before assuming either way.
Don't Forget About HSA and FSA Funds
If you have an HSA or FSA, eligible therapy expenses can generally be paid using those pre-tax funds.
That's not the same as getting reimbursed by insurance, but it can still make private-pay therapy less expensive overall.
If you have one, check your plan's rules before automatically paying for therapy entirely out of your regular take-home income.
Ask About Sliding Scale Too
Some therapists reserve a limited number of sliding-scale or reduced-fee spots for clients who can't afford their full fee.
Not every therapist offers them, and availability may be limited, but it's completely reasonable to ask.
You don't need to write an essay explaining your financial situation.
“Do you have any reduced-fee spots available?”
That's enough.
What Is a Superbill for Therapy?
A superbill is basically a detailed receipt containing the information your insurance company needs to process an out-of-network therapy claim.
It typically includes things like the date of your session, the service provided, your therapist's information, the amount charged, the procedure code, and the diagnosis code.
You pay your therapist, receive the superbill, submit it to your insurance company, and your insurer processes it according to your benefits.
You can absolutely do this yourself.
But if reading that sentence already made you tired, there are services that can help.
Reimbursify, Mentaya, and Thrizer: What's the Difference?
All three are designed to make out-of-network therapy benefits easier to use.
They don't create insurance coverage you don't already have. Your reimbursement still depends on your individual plan.
Here's the easiest way to think about them.
Reimbursify: “I Don't Want to File These Claims Myself.”
You see your therapist and pay the session fee.
Instead of figuring out your insurance company's claim process yourself, Reimbursify helps you submit the out-of-network claim.
Your insurer processes the claim and sends you whatever reimbursement you're entitled to under your plan.
Basically:
You pay your therapist → the claim gets submitted → insurance processes it → you receive eligible reimbursement.
The important thing to understand is that you're generally still paying your therapist upfront.
Best for: Someone who can pay the therapist upfront but doesn't want to deal with filing claims.
Mentaya: “Can Someone Help Me Figure This Out and Handle It?”
Mentaya can help with another frustrating part of this process: figuring out what your out-of-network benefits actually are.
Their benefits tools can help estimate what your insurance may reimburse, giving you a better idea of what an out-of-network therapist could actually cost you.
Mentaya can also help with claim submission and insurance follow-up.
Best for: Someone who wants more support navigating the overall out-of-network process.
Thrizer: “I Can Afford My Portion, but I Can't Float the Full Fee.”
This is an important problem that doesn't get talked about enough.
Maybe your eventual cost after insurance reimbursement is manageable.
But paying $200 every week and waiting for insurance to reimburse you isn't.
Those are two different affordability problems.
For eligible clients, Thrizer offers a payment option that can allow you to pay your estimated portion while Thrizer handles the insurance reimbursement process.
So instead of:
Pay the full therapist fee → wait for insurance → get reimbursed
the experience may look more like:
Pay your estimated portion → Thrizer handles the insurance reimbursement
Eligibility depends on your benefits, deductible status, and other factors, so this isn't available in every situation.
But it addresses a very real barrier.
You may be able to afford your portion of the session without being able to afford the therapist's entire fee upfront every week.
Best for: Someone whose biggest barrier is cash flow while waiting for insurance reimbursement.
Before You Decide You Can't Afford an Out-of-Network Therapist
First, look at what kind of insurance plan you have.
If you have a PPO or another plan with out-of-network benefits, call the number on the back of your insurance card and ask:
Do I have out-of-network benefits for outpatient mental health or psychotherapy?
What is my out-of-network deductible?
How much of it have I met?
After I meet my deductible, what percentage do you reimburse?
Is that percentage based on the therapist's fee or your allowed amount?
What is the allowed amount for an out-of-network psychotherapy session?
Do I need prior authorization or have any other requirements?
Then ask the therapist:
Do you provide superbills?
What diagnosis would be submitted if I use my out-of-network benefits, and why?
Do you work with Reimbursify, Mentaya, Thrizer, or another reimbursement service?
Do you have any sliding-scale or reduced-fee spots available?
If you have an HSA or FSA, check whether you can use those funds for eligible therapy expenses too.
Now you're making the decision with actual information instead of assuming that “out of network” automatically means “unaffordable.”
Paying Privately? You May Be Entitled to a Good Faith Estimate
There's one more thing worth knowing if you're not using insurance.
Under federal rules implementing the No Surprises Act, people who don't have insurance or aren't using insurance to pay for their care generally have the right to receive a Good Faith Estimate of the expected cost of scheduled healthcare services when the requirements apply.
That includes mental health care.
In plain English:
You have a right to know what you're expected to be charged.
It doesn't mean your therapist has to predict exactly how long you'll be in therapy.
It means you shouldn't have to enter private-pay healthcare without information about what the provider expects to charge you.
You can ask:
“Can you provide me with a Good Faith Estimate of my expected costs?”
Knowing what something costs is part of being able to make an informed decision about your care.
So, Is an Out-of-Network Therapist Worth It?
There's no right answer for everyone.
For some people, seeing an in-network therapist is the financially realistic choice. There are wonderful therapists who accept insurance, and using your benefits can make ongoing therapy significantly more affordable.
For other people, going out of network gives them access to a particular therapist, specialty, approach, or kind of therapeutic relationship they haven't been able to find in network.
The important thing is not to assume:
“Out of network = I have to pay the entire fee myself.”
Sometimes that's true.
Sometimes it isn't.
Find out what your benefits actually are. Ask questions. Look at the numbers. Ask the therapist what using insurance would mean.
Then decide what makes sense for you.
Don't let the words “out of network” make the decision for you before you have the information to make it yourself.
Looking for an Out-of-Network Therapist in California?
If you're looking for therapy that's less about fixing what's “wrong” with you and more about understanding who you are, where your patterns came from, how your relationships became what they are, and who you want to become, you can learn more about working with me for individual therapy in California.
You can read about my approach, fees, and what it's like to work together and decide whether I might be the right fit for you.
And if you have Aetna, remember that the practice I currently work with is in network. You may be able to use your in-network benefits.
If you have another plan and don't know what your out-of-network benefits are yet?
That's okay.
Check first. You might be surprised by what your plan actually covers.
This article is for general educational purposes and isn't insurance, financial, tax, or legal advice. Insurance benefits vary significantly by plan. Always verify your specific coverage, deductible, reimbursement, allowed amount, and claim requirements directly with your insurer. Features, eligibility, and pricing for third-party reimbursement services can also change, so confirm current terms directly with the service before enrolling.
