Guide to Out-of-Network Benefits

Matthew R. Houston, LCSW, does not participate in any insurance plans. He is considered an out-of-network provider. Payment is due at the time of services unless other arrangements have been made. Many health insurance plans offer substantial out-of-network benefits, which will reimburse a generous portion of your treatment costs. Mr. Houston will provide you with an itemized receipt so that you may submit a claim to your insurance company.

Please use the following worksheet to learn more about your individual insurance plan’s benefits as you assess your out-of-pocket expenses. Call the number on the back of your insurance card and ask your representative the questions below.

  • Note the date and time of the call. Ask the representative for his/her name and direct contact number.

  • “Does my insurance plan include out-of-network benefits for outpatient behavioral/mental health? If so, what are the benefits?”

  • “Do I need to obtain prior authorization to have these services covered?”

  • “Is there a limit on the number of sessions my plan will cover per year?”

  • “Does my plan have an annual out-of-pocket maximum (which is usually the sum of my deductible and co-insurance) that I am expected to meet before my benefits kick in? If so, what is the amount?” o “How much of my deductible have I met?” (What is the remaining amount?)

  • “When my benefits do kick in, how much will be covered, and how much will I be responsible for? (For example, a plan might have an annual out-of-pocket maximum of $1000. After I have spent this much, my plan will reimburse 100% of the services).

  • “What is the Usual, Customary, Reasonable Fee, also known as the Allowed Amount for New York City in Area Code 10010? I know that it is usually between $250 – $300 a session.” (They will probably not tell you this information and state that it is “proprietary,” which is not true – you are entitled to know what your plan sets as the “allowed amount.”)

  • “Are there specific claim forms that I must submit, and in what time frame do claims need to be submitted? Where do I submit the claims?”

  • “What is the policy year, and when does my deductible plan reset (i.e., Jan 1 – Dec 31; July 1- June 30)?”