Why Your Insurance Company Won’t Cover Couples Therapy

One of the great benefits of recent years of mental health awareness has been the increase in access to mental health treatment via health insurance. As mental health conditions, which nearly 1 in 5 people are currently living with, often occur throughout a person's life, they require periods of treatment with a goal of management rather than cures. This also means having times of significant financial cost unless insurance deems it to be medically necessary and is an expectation of your agreement with them. Mental health parities have allowed therapy to be more obtainable than ever for those struggling with their mental health. 

    However, not all therapy is treating a medical disorder; it can also be about improving self esteem, exploring sexuality, and improving components of life that are no longer serving you. As this alone tends not to meet the criteria of medical necessity, insurance would not be expected to pay. These types of intricacies and loopholes are not commonly discussed, and this post is to more clearly explain the current requirements.

So, what does that mean about couples?

    With couples therapy, there can be mixed signals about whether it can be covered by insurance or not, and these signals can be given by insurance, others who have seen a therapist as a couple, and even therapists. To help better understand, it is important to know that there are particular types of codes that therapists are and are not allowed to bill services to your insurance for, and the one you'll hear about here is 90847: Family Therapy. There is no actual billing code for couples therapy, and this will make sense in a moment.

In couples therapy, the relationship is the client. 

    Couples therapy focuses on the relationship and works towards the interest of the relationship, not one person or another. Common focuses are communication, conflict, trust, respect, division of labor, infidelity, exploring sexuality, exploring separation, etc. The therapist's role is to work towards the client's well-being, in whatever way that means. 

Who does insurance cover then?

    Comparatively, 90847 Family Therapy is a code used for the use of systemic family therapy with the goal of treating the identified patient's diagnosed mental health disorder. This requirement is set by Medicare which most insurances tend to follow, and some further restrictions can also apply, as some insurances require the couple to be married to consider it "family" therapy. These sessions are focusing on the goal of improving that person's symptoms, and benefits to the relationship as a whole is a secondary bonus. This can look like helping someone better support their spouse's anxiety disorder management or educating and finding new patterns for a couple with one neurodivergent partner whose symptoms create a cycle of frustration and lashing out by the neurotypical partner. These therapies can be vital and are important; they are just different than couples therapy because they aren't about the couple.  

Can't we try insurance, and see what happens?

    Therapists sign contracts with insurances as well when they agree to become part of their network, and one of the most important requirements of it is to engage in honest, ethical billing. While the vast majority of therapists share the opinion that relationships have impact on our overall health and well-being and an ounce of prevention is worth a pound of cure, they still have to abide by the definitions they agreed to. Knowingly submitting something that doesn't meet criteria would fall outside of ethical billing, and audits regularly happen specifically to find these situations, causing headaches all around including you now being responsible for the cost of session. It works much better for everyone involved to have ethical billing from the start. 

Where does that leave us?

    Now that you understand the difference between these two therapies, you can make your expectations according to what your goal is. If the goal is to help one person with their mental health challenges and how the relationship is impacting them, then there is a good chance insurance will be willing to cover it. If the goal is to improve the relationship, then you will want to plan for private pay. Being able to understand these important nuances more commonly seen in couples therapy and articulate your goals and having an open discussion with your therapist will help you establish your path forward.