Reimbursement: Insurance or EAP

Ask your insurance provider or company’s EAP about your mental health coverage or benefits.  Providers and health care programs reimburse at different rates.  They consider your diagnostic code, the time that you spend in the therapy, and the expertise of the mental health care provider. 

Your statements for insurance reimbursement are available to you via your client portal.  Your insurance company will need you to preauthorize your treatment, submit your insurance reimbursement forms, and to be aware of coverage limits as ultimately, you are financially responsible to pay for services provided.

Insurance providers or EAPs require preauthorization just like seeing any medical specialist.  You may receive a referral from your primary care provider to see someone about difficulties in your relationship that negatively affect your current functioning, health, and/or sense of well-being.  People seek couple’s therapy often after the distress from the relationship problems have begun to significantly erode well-being and health.  So, see your primary care provider and then call your insurance provider or simply call your carrier first and see what they are willing to reimburse.  

Importantly, the 90847 CPT code for ‘couple’s therapy’ is really a code for the covered person which will not reflect the mental or medical status of the other partner.  And equally important, only 1 person’s insurance may be used to cover a session with the doctor. 

Marathon sessions are longer in nature, lasting much longer than options covered by EAPs or insurance providers.  Standard coverage times are limited to half an hour to one hour.  

While early research tends to demonstrate very good outcomes for couples who pursue marathon work, very few providers reimburse for marathon couple’s work.  You may inquire from your insurance provider if you have coverage for CPT 90791 (and whether you have already used your benefit for 90791 this year).  Using the Gottman Method means having an initial assessment (CPT 90791).  As such, your insurance may reimburse for 90791 + 99345 followed by an additional coverage of CPT 90847 the following day.  Knowing to inquire and preauthorize these codes can help you to secure additional reimbursement.  

Even while some of the costs of your marathon session may not be covered, the benefits and convenience of addressing couple’s problems in a marathon, in terms of: less coordinating of multiple schedules, reducing travel times/costs, and reducing the schedule strain required for weekly meeting times, often outweigh the associated costs.  For example, for parents, finding babysitting coverage for 1-2 days may be easier than finding weekly coverage–it often depends on your situation.

Many EAP programs reimburse for the “7 Principles for Making Marriage Work” or “Bringing Baby Home” workshops. The Gottman Institute demonstrated significant improvements in quality of life with significant reduction in billed therapy later in life for individual mental health and/or for therapy to address relationship problems.

If seeking coverage or reimbursement with your company’s EAP, let them know that many bigger companies are offering to cover all of (Amazon, Google, SalesForce) or a significant portion of the cost of the workshop.  Two workshops connected to the Gottman Institute that have been covered by companies’ Employee Assistance Programs have been the: Bringing Baby Home workshop/classes and the 7 Principles for Making Marriage Work workshop/classes.  Both of these workshops/classes are offered by Dr. Mason in group format and in private or semi-private (2-6 couples) format.  

Using your HSA money to pay for sessions?  Dr. Mason is consulting with a tax specialist to track regulations about using this benefit.  Stay tuned.