Does Blue Cross Cover Marriage Counseling?

    Does Blue Cross Cover Marriage Counseling

    Marriage counseling can be a crucial part of maintaining a healthy relationship, yet the cost may deter some couples from seeking the help they need. If you have health insurance through Blue Cross Blue Shield (BCBS), you may be wondering – does Blue Cross cover marriage counseling?

    In this comprehensive guide, we’ll break down the different types of Blue Cross plans and what they typically cover when it comes to behavioral health services like marriage counseling. We’ll also discuss important factors that determine your specific benefits and provide tips for maximizing your coverage.

    Let’s get started.

    Understanding Your Behavioral Health Benefits

    Nearly all BCBS health plans include some level of coverage for behavioral healthcare services that treat mental health and substance use disorders. This includes individual, group, family, and employee assistance program (EAP) plans. However, the extent of coverage can vary significantly depending on your specific plan.

    Blue Cross categorizes behavioral health services under the broad term “mental health and substance use disorder benefits.” This includes treatments provided by psychologists, clinical social workers, psychiatric nurse practitioners, and other licensed mental health professionals. It also encompasses counseling services for issues like depression, anxiety, trauma, grief, and relationship problems.

    Traditionally, many behavioral health services required higher copays or coinsurance than medical/surgical benefits. However, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act have required parity between behavioral health and medical benefits for most major medical plans.

    So in summary – while all BCBS plans include some level of behavioral health coverage, the exact services covered and your out-of-pocket costs depend greatly on your specific plan type and details. The good news is that marriage counseling is generally considered a covered behavioral health benefit, though requirements vary as we’ll explore below.

    Does Blue Cross Cover Marriage Counseling?

    If you get insurance through your or your spouse’s employer, you most likely have a group health plan with BCBS. Group plans universally cover basic outpatient mental health services, which would include short-term marriage counseling provided by a licensed therapist or counselor.

    Here are some key things to know about marriage counseling coverage under Blue Cross group plans:

    Copays/Coinsurance: Most BCBS group plans cover 50-80% of the cost of outpatient counseling/therapy after a copay of $20-50 per session. Higher-end plans may have lower or no copays.

    Visit Limits: Some plans limit coverage to 10-20 counseling sessions per issue per year. Others may have unlimited visits. More restrictive plans often have exceptions processes to extend limits if medically necessary.

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    Network Providers: For full coverage, use therapists/counselors within your plan’s provider network. Out-of-network costs dramatically more with lower reimbursement rates.

    EAP Benefits: Many large employers offer Employee Assistance Programs providing free short-term counseling through an EAP network, separate from regular health benefits.

    So in summary, BCBS group plans virtually always cover basic outpatient marriage counseling, especially when using in-network providers. Just be aware of any session limits or cost-sharing your specific plan requires. As long as counseling meets medical necessity guidelines, coverage is very likely.

    Individual & Family Plan Coverage

    If you purchase your BCBS health insurance plan individually or through rather than through an employer, coverage for marriage counseling can still be available but varies more by plan:

    ACA-Compliant Plans: These plans offered on/off-exchange are required to cover behavioral health services considered “essential health benefits”, including outpatient counseling. Copays may be higher than group plans starting around $30-50 per visit.

    Access Blue Plans: BCBS individual plans in some states like SC and GA. Typically mirror group plans with copays/coinsurance for outpatient counseling benefits and network requirements.

    Short-Term Plans: Non-ACA compliant fixed indemnity or short-term plans may have no behavioral health coverage or cover a limited number of counseling sessions annually. Check plan details carefully.

    HMO Plans: Often require counseling services provided by network therapists at lower copays. May deny out-of-network claims entirely. Verify provider networks are sufficient locally.

    So while coverage varies more than employer plans, most major medical individual plans from BCBS should cover at least a portion of costs for initial marriage counseling provided in-network by a qualified provider like a licensed marriage and family therapist. Just factor cost-sharing into your care decisions.

    Deciding Which Therapist is Right

    Once you determine marriage counseling is generally covered under your BCBS plan, you need to choose the right therapist or counselor.

    Licensed marriage and family therapists (LMFTs) specialize in relationship issues and are generally considered in-network providers. However, licensed clinical social workers (LCSWs) and counselors are often also credentialed to provide counseling benefits under BCBS plans.

    Other types of therapists like psychologists often provide testing or diagnostic services that may not be covered as standard counseling claims. And psychiatrists tend to focus more on medication management than talk therapy.

    When deciding on a therapist/counselor, consider:

    Specialty in relationships: Ensure they treat issues like communication breakdowns, intimacy problems, parenting disagreements and have experience with couple dynamics.

    Insurer’s provider network: Verify prospective therapists actually accept your BCBS plan to avoid higher out-of-pocket costs if they aren’t in-network.

    Your goals/needs: Discuss with the therapist what exactly you hope to gain from sessions – insight, tools for change, etc. Make sure their style aligns.

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    Choosing the right BCBS network provider with relationship expertise will help maximize your counseling benefits and progress towards healthier dynamics with your partner. Take some time to vet potential therapists through referrals or online profiles when selected.

    Submitting Claims & Negotiating Gaps in Coverage

    Once counseling begins with an in-network BCBS provider, billing and payments should be fairly straightforward. Your therapist will likely submit claims directly to BCBS and collect only applicable copays or coinsurance due from you. Out-of-pocket maximums ensure costs will not eclipse a certain threshold annually.

    However, there may be times coverage gaps arise. For instance:

    Session limits reached: If you exceed the behavioral health visit cap for the year, ask your therapist about extending care based on medical necessity. Provide treatment summaries and relevant documentation.

    Complex issues: Relationship problems intertwined with other behavioral health conditions like depression or trauma could potentially qualify for expanded coverage. Discuss diagnoses with your therapist.

    Billing mistakes: Often simple oversights not actual denied claims. Have your therapist verify codes, networks, etc. and resubmit as needed.

    Appealing claim decisions: If unsatisfied with denial reasoning, submit appeal through standard BCBS process citing supporting details from your treatment. Success rates for legitimate denials are high.

    Collaborating professionally and persistently with your BCBS plan administrator and therapists is key if care seems prematurely discontinued due to policy-based limits rather than clinical readiness. With cooperation, potential gaps can usually be addressed.

    Maximizing Your Marriage Counseling Coverage

    With the right strategy and diligence, you can get the full counseling support you need under your BCBS behavioral health benefits without depleting savings. Some final tips:

    • Check policy details and call BCBS with any questions about coverage specifics before care begins.
    • Coordinate care across providers treating related issues for possible broader benefits.
    • Consider out-of-pocket deductible status and shifting care to earlier benefit period with lower costs if applies.
    • Ask primary care doctor to refer you for a “behavioral health assessment” triggering expanded authorization when medically necessary.
    • Research therapy options if concerns escalate outside scope of outpatient counseling benefit, e.g. intensive outpatient treatment.
    • Seek alternative funding if relationship issues intensify, like Employee Assistance Program, community clinics on a sliding scale.

    With proper preparation, diligence following through on claims, and partnership with your BCBS plan and providers, marriage counseling need not represent an insurmountable obstacle. Many couples each year find the help they require through wise use of behavioral health benefits.

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    Frequently Asked Questions

    How many sessions does Blue Cross typically cover for marriage counseling?

    Most Blue Cross plans cover 10-20 counseling sessions per issue annually before requiring pre-authorization for additional treatment. However, coverage limits vary greatly by specific group or individual policy so be sure to check your plan details.

    Can my spouse and I see the same marriage counselor together?

    Yes, seeing the same therapist is considered marriage counseling and is covered under most BCBS plans. Just be sure your counselor specializes in relationship issues and is an in-network provider for your plan to avoid extra costs.

    Will Blue Cross cover online marriage counseling or counseling over the phone?

    Telehealth services have expanded rapidly during the pandemic. Many BCBS plans now cover certain online counseling sessions or phone consultations, especially in rural areas. However, coverage can still vary significantly between individual policies. Be sure to check with your specific BCBS plan to confirm teletherapy is a covered benefit. Most require the online therapist be licensed in your state. Teletherapy is generally subject to the same cost-sharing as in-person sessions, like deductibles and copays.

    Can I use my FSA or HSA funds to pay for marriage counseling?

    If you have a Flexible Spending Account (FSA) through your employer, funds in your FSA can generally be used tax-free to cover any out-of-pocket expenses for counseling that aren’t fully paid by your BCBS plan, such as copays and coinsurance. The same applies to funds in a Health Savings Account (HSA) as long as the counseling qualifies as tax-deductible medical care under IRS rules. Just be sure to save all documentation in case of an IRS audit.

    What if my counseling needs extended beyond standard coverage?

    If standard outpatient counseling sessions prove insufficient to fully address your relationship problems, discuss options with your therapist. Some BCBS plans cover intensive outpatient programs (IOP) involving group therapy multiple times weekly. Alternatively, your therapist may recommend submitting a pre-authorization request to BCBS for additional outpatient sessions by documenting medical necessity. As a last resort, investigate community mental health centers operating on a sliding scale basis.

    Is marriage counseling confidential under HIPAA?

    Yes, all communication between you and your marriage counselor is protected under HIPAA rules as confidential patient information. Your counselor cannot disclose details of your treatment without your consent, even to your spouse. Some exceptions include if your safety or others is at imminent risk, or if records are legally subpoenaed. Discuss any concerns on confidentiality openly with your counselor when starting treatment.



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