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Does Aetna Cover Couples Counseling?

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Does Aetna Cover Couples Counseling

Marriage and long-term relationships can face many challenges along the way. Seeking help from a licensed couples counselor or therapist can be a smart decision for any couple experiencing difficulties.

However, the cost of therapy may give some pause. In this comprehensive guide, we’ll explore whether and how Aetna health insurance covers couples counseling so you can make an informed decision about prioritizing your mental health and relationship.

What is Couples Counseling?

To understand insurance coverage, it’s important to define what couples counseling entails. Couples counseling, also known as marriage counseling or couples therapy, involves regularly scheduled therapy sessions with a licensed mental health professional.

The counselor works with both partners together to address relationship issues, improve communication skills, resolve conflicts in a healthy way, strengthen emotional intimacy and connection, and build a stronger, more fulfilling relationship overall.

Therapy sessions typically involve open communication between partners, practicing active listening skills, identifying negative thought and behavior patterns, developing compromise, building empathy, and setting shared goals for the future.

Counselors use techniques like Cognitive Behavioral Therapy to help couples recognize unhelpful thought patterns and replace them with more constructive ones. Some of the most common issues addressed in couples counseling include:

  • Lack of effective communication or frequent arguing
  • Loss of intimacy or emotional distance between partners
  • Financial stressors putting strain on the relationship
  • Issues around parenting styles or disagreements on raising children
  • Loss of trust due to infidelity or other relationship breaches
  • Depression, anxiety, or other mental health concerns impacting one or both partners
  • Life transitions like having a baby, empty nesting, retirement putting stress on the relationship

The overarching goal is to improve understanding between partners, manage conflict in a healthy way, and create sustained positive changes to strengthen their bond and commitment to one another long-term. Regular therapy provides guidance and accountability during this process.

Does Aetna Cover Couples Counseling?

Now that we understand what couples counseling entails, let’s examine whether and how Aetna health insurance plans cover the costs. The good news is that most Aetna plans do include at least some coverage for couples/marriage counseling. However, the specifics can vary depending on your individual policy.

Aetna considers licensed marriage and family therapists to be “in-network” mental health providers across most plans. This means couples counseling sessions performed by an appropriately licensed counselor would typically be covered after any applicable copays or deductibles are met based on your plan type and level of coverage.

Some key factors that determine Aetna couples counseling coverage include:

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Plan Type: Health maintenance organization (HMO), preferred provider organization (PPO), or other plan type impacts coverage details. PPO plans tend to offer more flexibility.

Deductible: You must meet the annual combined medical/behavioral health deductible before most coverage begins for counseling.

Copays: Once the deductible is met, counseling visits may require set copay amounts (e.g. $30/visit) depending on the plan.

Visit Limits: Some plans cap coverage at a certain number of therapy visits per year (often around 20-30 combined medical/behavioral health visits).

In-Network Providers: Only counseling received from an in-network provider is fully covered based on your benefits. Out-of-network providers may result in higher out-of-pocket costs.

Cost-Sharing: Premiums, deductibles, copays, and coverage percentages are all important to understand for your specific Aetna plan.

To get precise details on your couples counseling coverage, log in to your Aetna member account or contact a customer service representative. They can provide a benefits summary stating things like exact deductible amounts, visit limits, covered counseling codes, and in-network provider search tools.

Maximizing Your Aetna Coverage for Counseling

While most Aetna plans do include at least some couples counseling coverage, there are still potential out-of-pocket costs to consider depending on plan design features. Here are some additional tips for maximizing your coverage:

Use Telehealth: During COVID-19, many insurers expanded coverage for teletherapy/telepsychiatry sessions. Virtual counseling may lower costs vs. in-person visits depending on your plan.

Check for Wellness Programs: Some Aetna plans offer wellness programs waiving cost shares for preventive counseling services like couples therapy within certain clinical guidelines.

Request Pre-Authorization: Inquire if a pre-authorization is required for extended counseling services. This ensures planned visits are covered upfront to avoid unexpected denied claims.

Search Provider Directories: Carefully choose an in-network counselor from Aetna’s provider search tool to avoid higher bills. Pay attention to counselors accepting new patients.

Combine with FSA/HSA Funds: Set aside pre-tax dollars annually in a Flexible Spending or Health Savings Account to use toward counseling deductibles and coinsurance costs not covered by insurance.

Inquire about EAP: Employee Assistance Programs through workplace insurance sometimes offer a few free counseling sessions that don’t count against medical benefits.

Maximizing available benefits can lower the financial barriers to getting quality professional help when you and your partner need it most to invest in your relationship wellbeing. Proactive planning is key for budgeting couples counseling costs under your Aetna plan.

Covered Counseling Diagnosis Codes

For a mental health claim like couples counseling to be covered by insurance, the provider will need to submit an appropriate diagnosis code from the ICD-10-CM manual. There are a few codes commonly used for couple/marriage counseling that Aetna generally considers covered conditions:

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Z71.81: Partner Relational Problem: Used when relationship issues between romantic partners are impacting their functioning and warrant counseling intervention.

F39: Other Specified Mood (Affective) Disorder: Applies when relationship stress is contributing to a partner’s underlying mood issues like depression or anxiety.

R26.81: Partner Relational Problem: Similar to Z71.81 but applicable in some gender neutral or same-sex relationships as well.

F41.9: Unspecified Anxiety Disorder: May be used if one partner’s anxiety around relationship problems is impairing their daily life.

F43.21: Adjustment Disorder With Anxiety: Fits acute anxiety/stress response to relationship strain or other interpersonal triggers being addressed in counseling.

Getting an appropriately corresponding ICD-10 diagnosis code from the counseling professional is important to verify the services meet Aetna’s medical necessity criteria and are deemed covered benefits under your plan. This prevents any potential claim denials down the line after sessions take place.

Exceptions and Exclusions to Watch Out For

While the majority of cases are covered by Aetna plans as counseling is recognized as a valuable treatment, there are a few exceptions where services may not be fully or partially covered:

Educational Services: Purely psychoeducational classes or programs teaching relationship skills are generally excluded unless part of a treatment plan.

Court-Ordered Treatment: Counseling mandated solely by the legal system for things like domestic disputes may not be covered.

Custody Evaluations: Assessments performed for child custody determinations in divorces are excluded.

Sex Therapy: Some plans have separate coverage criteria or cost-shares for sexual dysfunction treatment beyond regular therapy.

Out-of-Network Providers: Using an out-of-network counselor can result in partial or non-coverage of costs depending on plan specifics.

Pre-Existing Conditions: Services for any pre-existing mental health issues identified during the open enrollment period may be subject to wait periods or other restrictions.

Being aware of potential policy exceptions is prudent. Contact Aetna ahead of time if your counseling needs fall outside typical relational issues to verify anticipated costs will qualify as covered benefits. Clear financial assumptions are important for budgeting care.

Appealing Denied Claims

In rare cases, a claim for couples counseling services may be denied by Aetna for reasons outside your control like coding errors. Insurance companies are also sometimes overly strict about medical necessity determinations against professional guidance.

If this happens, don’t give up. Most policies allow for written appeals when you feel coverage was wrongfully denied:

  • Request an Explanation of Benefits noting the specific denial reason(s).
  • Gather records supporting your counseling is clinically deemed medically necessary by licensed experts.
  • Submit a formal written appeal letter within 180 days of claim denial accompanied by any additional documentation.
  • Cite policy language supporting your claim for covered benefits if possible.
  • Escalate to external review by your state department of insurance as needed.
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You deserve seamless access to care. Pursuing appeals ensures proper application of your coverage and holds insurance accountable to pay valid claims as contracted. Don’t hesitate to fight unjust denials with your counselor’s support.

Frequently Asked Questions

With so many nuances to insurance coverage, other questions may remain. Let’s tackle a few more FAQs:

Q: What if my partner and I need couples counseling but we have different health plans?

A: Even if you and your partner have separate health insurances, most plans will cover couples counseling as long as one partner is seeing an in-network provider for medically necessary treatment. The counselor would bill the attending partner’s insurance as primary.

Q: How can I find an in-network couples counselor?

A: The best way is to use Aetna’s online provider search tool. You can filter for “Marriage and Family Therapists” in your location accepting new patients. Check licensure and credentials closely. Don’t hesitate to call offices asking if they specialize in couples counseling.

Q: What sorts of issues warrant professional counseling versus working through on our own?

A: Seeking help is recommended if conflict is chronic, heated arguments are frequent, one or both partners are struggling with private emotional distress, abuse/affairs have occurred, or independent conflict resolution efforts aren’t producing lasting solutions. Professional guidance provides perspective, skills, and accountability to make real changes.

Q: Our schedule is busy. Can counseling be done virtually or via phone?

A: Absolutely. Many counselors now offer teletherapy as an option utilizing secure video conferencing or phone. Virtual sessions are often billable to insurance the same as in-person. This provides added flexibility which can help busy couples stay on track with their treatment goals. Just double check your plan’s rules on telehealth coverage.

Q: What if we don’t want to do traditional talk therapy – are there other options?

A: Couples can also benefit from alternative modalities like EMDR, art therapy, or body-centered approaches depending on individual needs. Some counselors specialize integrating nontraditional techniques. Discuss options upfront to find the best fit. The overall goal is feeling understood and supported through any evidence-based treatment model.

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