Using Your Health Insurance
Your Insurance Coverage
It is your responsibility to cover the cost of your mental health care. Most insurance plans have benefits for mental and behavioral health services. If you’re not sure what your benefits include, it may be helpful to call your insurance to learn more about your coverage. To avoid any surprises about the cost of your treatment, you may call your insurance company to verify your coverage and ask about the cost associated with specific providers.
You may want to ask your insurance the following questions:
- What is my deductible? How much have I currently paid toward my deductible?
- Does my deductible apply to in-network mental health services?
- Does my deductible apply to out-of-network mental health services?
- What are my in-network mental health benefits?
- Do I need to pay a copay for each visit? If so, how much is the copay?
- Is there a limitation on the number of visits I am allowed? Does the copay change after a certain number of visits?
- What are my out-of-network mental health benefits?
- Do I need to pay coinsurance for each visit? If so, how much is coinsurance?
- How can I find the “allowed rate” or “usual, customary, reasonable” (UCR) rate to know how much I will be paying in coinsurance?
In-Network vs Out-of-Network
When looking for a therapist, you have the option to choose between in-network and out-of-network providers. In-network therapists have negotiated a contracted rate with your health insurance company; as a result, they are typically more affordable than out-of-network therapists.
While finding an in-network therapist is often the default choice, including out-of-network therapists can help expand your therapist search. This is especially true in big cities like Washington D.C., where therapists who take insurances tend to be booked to full capacity and have long wait times for appointments.
If you work with a therapist who is not in your insurance network, then you will have to pay the full price of the session upfront. Fortunately, depending on your plan, your insurance company may help reimburse a portion of the cost. You may submit a claim to your insurance for out-of-network benefits. Make sure that you know your specific plan’s out-of-network benefits so that you can make an informed decision about your finances. Some insurance plans reimburse up to 80% of the out-of-network fee once the deductible has been met! This may depend on your individual insurance plan and CAPS recommends that you find out more about your insurance coverage.
While in-network payment may seem straightforward, you also need to consider your deductible to determine the total cost of a therapy session. Any medical expense, such as a doctor’s visit or medication prescription, contributes to reaching your deductible. When you have paid enough in medical costs that the sum of costs equals your deductible, it often referred to as “meeting your deductible.” The amount of your deductible is specific to your insurance plan. While the Student Health Insurance (GUSHI) has a deductible of $250, other students may have insurance with a much higher deductible of $5,000. Please call your insurance company to learn more about your deductible & coverage.
Georgetown University Student Health Insurance (GUSHI)
Overview of Costs Associated with GUSHI 2020-2021
Treatment with In-Network Providers
Co-Payment: $25 for an Outpatient Physician or Mental Health Visit
Co-Payment: $50 for an Urgent Care Visit
Co-Insurance: 10%, e.g., labs, tests, inpatient, miscellaneous services
Treatment with Out-of-Network Providers
Plan Year Deductible: $250
Co-Payment: $50 for an Urgent Care Visit
Co-Insurance: 30% of reasonable charges and any remaining charges over and above usual and customary
GUSHI may reimburse you for a certain percentage of fees associated with out-of-network fees. To receive that reimbursement, you must submit your claim to GUSHI.
Submit Out-Of-Network Claims Online to GUSHI
First, go to: www.UHCSR.com and log into MyAccount. Select “Submit Claim” from the My Account dashboard. From the Claims submission tab select “Submit Claim” to open the online form.
Next, select the claim type: Medical, Prescription or Foreign Claim.Complete the requested information and upload applicable documents, receipts, etc. Submit the form.
After, the claim has been submitted it will be reviewed. If additional information is needed you will receive an email from UHCSR. Once the claim has been processed access the “Claims Summary” tab to view the final details.
Healthiest You by Teladoc
GUSHI has partnered with Healthiest You by Teladoc to provide access for non-emergencies to licensed mental and medical health professionals online or by telephone, 24/7, without charge for premier members. Find out more information about accessing these telehealth services here.
Learn more about GUSHI
- Find in-network providers: United Healthcare Student Resources
- Learn more about your insurance benefits: Georgetown University Student Health Insurance Office
The amount you are responsible to pay each plan year before the insurance company starts paying. Depending on your plan, your annual deductible may not apply to mental health services at all, it may apply only to out-of-network mental health services, or it could apply to all mental health services.
A provider is in-network for you if they have an agreement with your insurance company to provide care to members with your plan. When seeing an in-network provider, your in-network benefits apply.
A provider is out-of-network for you if they do not have an agreement with your insurance company to provide care to members with your plan. When seeing an out-of-network provider, your out-of-network benefits apply. Some plans do not have out of network benefits.
A fixed amount you pay when you receive care that is subject to a copay. Copays often range from $0-30 and are most often required by plans when using in-network benefits.
Coinsurance is a portion of the medical cost you pay after your deductible has been met. Coinsurance is a way of saying that you and your insurance carrier each pay a share of eligible costs that add up to 100 percent.
Coinsurance is the amount you pay that is a percentage of the “UCR” (Usual, customary, reasonable) or “allowed” rate for the care you receive. For example, your health plan might decide that the “UCR” for a 60-minute psychotherapy session is $100. If your out-of-network mental health benefit is 20% coinsurance and the provider’s fee is $100, then you pay $20 per visit and your insurance company pays the remaining $80. If the provider’s fee is $200, the insurance company still only covers 80% of the UCR (80% of $100), so they would cover $80 and you would be required to cover the 20% coinsurance (20% of $100 = $20) in addition to the difference to meet the providers fee ($100). So in total, in this example, you would pay $20 + $90 = $110 per visit.
A sliding scale fee “slides” to try to meet the needs of clients who are unable to pay the full fee. Details can be discussed upon consultation with a provider.