What Open Enrollment Season Actually Means If You're Already Paying Out of Pocket for Therapy

Sep 28

Woman filling out health insurance information for open enrollment.

If your inbox looks anything like mine right now, open enrollment emails have started to land. "Your benefits, simplified!" 🙄 (Simplified is doing a lot of heavy lifting in that subject line.)

If you're already paying out of pocket for therapy here in Cincinnati, or you're weighing whether to, that's something to consider while figuring out health insurance plans.

So let's talk about what open enrollment can actually mean for you. I'll keep it plain, skip the jargon, and leave the guilt at the door. Whichever route you choose, there's no wrong answer here.

What does "out-of-network" actually mean?

"In-network" means a therapist has signed a contract with an insurance company, agreeing to set rates and rules. "Out-of-network" means a therapist hasn't signed one. That's the whole definition.

It doesn't mean unqualified, unlicensed, or unavailable to you. It's a business decision, not a quality rating in either direction. Many therapists work out-of-network because of paperwork demands, or because they want more say in how their sessions run.

You'll also hear the term private pay (or self-pay). That means you pay your therapist directly and insurance isn't involved at all. Out-of-network reimbursement is a middle path. You pay your therapist directly, then ask your insurance company to pay you back for part of it.

How does out-of-network reimbursement work?

First, a caveat. Not every plan includes out-of-network mental health benefits. Many PPO and POS plans do, while HMO and EPO plans often don't. Your plan documents will tell you for sure.

If your plan does include them, the process usually looks like this:

Pay your therapist at the time of your session.
Ask for a superbill. This is an itemized receipt with your therapist's information, the date of service, the service code, and a diagnosis code.
Submit it to your insurance company, usually through their online portal or a claim form.
Wait for reimbursement. Your insurer applies your deductible and pays back a percentage of what they consider the "allowed amount."

That last part is where people get surprised. Here's a made-up example: your session costs $150, your plan's out-of-network allowed amount is $100, and it reimburses 60% once your deductible is met. You'd get $60 back. Not $90, and not $150. Before your deductible is met, you may get nothing back at all.

Those numbers are examples only. Your plan's numbers are your plan's numbers, which brings us to homework.

What should you ask your insurance company during open enrollment?

Open enrollment is the one time of year you can actually change your coverage, so it's worth a phone call. Here's what to ask:

Does my plan include out-of-network outpatient mental health benefits?
Is there a separate out-of-network deductible, and how much is it?
What percentage do you reimburse after I meet it?
How do you calculate the "allowed amount" for therapy?
Is there a limit on sessions per year, or a pre-authorization requirement?
Do you accept superbills, or do I need to use your claim form?
How long do I have to submit a claim?

Call the number on the back of your card, and write down the date and the name of the person you spoke with. Yes, this is adult homework. I'm sorry.

Why do some people choose private pay even when insurance is an option?

Private pay usually costs more upfront, so it's fair to wonder why anyone would choose it when coverage is available. Here are the reasons I hear most often.

Diagnosis. To bill insurance, a therapist has to assign a mental health diagnosis, and it becomes part of your health record. Diagnoses can be genuinely helpful, and some people feel relieved by one. Others would rather not have a label attached to a hard season, a relationship pattern, or a family history. You're a whole person, not a code.

Session limits and reviews. Some plans cap the number of sessions or periodically review whether therapy is "medically necessary." Healing isn't linear, and it doesn't always fit into an approved number of visits.

Flexibility. Without an insurance company in the middle, there's often more room to decide how often you meet, how long sessions run, and how the work unfolds.

Privacy. Insurers can request clinical information when they review claims. Private pay keeps fewer people in the loop.

Choice. Your options aren't limited to whoever appears in your plan's directory. You can pick a therapist because they're the right fit.

None of this makes private pay "better." It's a tradeoff, and in-network care can be the right choice, or the only workable one, for plenty of people. The goal is to choose with your eyes open.

What does this look like for parents?

I work with parents who are worried about repeating patterns from their own childhoods. That kind of healing rarely fits neatly into a diagnosis or a set number of sessions. Someone might come in for parenting stress and realize the real work lives in their own history. The past is lived in the present, and it doesn't check your session count first.

Not being tied to a diagnosis code or a session limit means we can follow what's actually coming up, instead of what needs to appear on a claim form. That matters when we're using approaches like EMDR and Brainspotting, which tend to move at the pace your nervous system sets. It matters for kids, too. In Synergetic Play Therapy, healing grows out of attunement and co-regulation between child and therapist, not a checklist.

Clients often tell me the biggest gain is room. Room to go where the work is, to move at a pace that feels safe, and to be understood as more than a diagnosis. 🌱

Is it okay to ask about cost in a first conversation?

Yes. Truly.

Therapists talk about money too, and we'd much rather you ask than quietly wonder. At Conscious Roots Counseling, session fees range from $135 to $160 per hour. We can provide a superbill on request so you can submit for out-of-network reimbursement.

If cost is a question for you, bring it up in your first conversation. There's no guilt and no pressure. You'll get a straight answer, and you can decide what works for you and your family.

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Frequently Asked Questions

What's the difference between out-of-network and private pay?
With out-of-network care, you pay your therapist and may submit a superbill to your insurer for partial reimbursement. With private pay, you pay your therapist directly and don't involve insurance at all.

Can I use my insurance with an out-of-network therapist?
Sometimes. It depends on whether your plan includes out-of-network mental health benefits, your deductible, and your plan's allowed amount. Call your insurer and ask before you commit. We have a free guide for that conversation.

Does out-of-network reimbursement require a diagnosis?
Yes. Insurance claims typically require a diagnosis code, which is one reason some people choose private pay. Ask your therapist how they handle this.

When is open enrollment?
Employer plans often hold open enrollment in the fall, and Marketplace dates vary. Check your plan's deadlines so you don't miss the window.

This post is general information, not insurance or legal advice. Your plan's details may differ. 🫶