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I find most people are confused by health insurance in general. When it comes to something like sex therapy and couples therapy, details are even more nuanced and can be more confusing. Here’s information to help clarify what may be covered and what might not be covered.
Billing insurance has two elements; the code that indicates how much time you meet with a therapist and your diagnosis. In general, the code has less impact on if insurance will or will not coverer therapy. The diagnosis that a therapist is giving you has much more impact on if insurance will cover therapy. Insurance companies have guidelines as to what they think is medically necessary for a person to receive therapy.
Billing insurance for sexual health diagnosis is not possible because insurance does not consider it medically necessary for therapy. There is a 947-page book called the Diagnostic and Statistical Manual of Mental Disorders. This book is used by a therapist to diagnosis a person with a mental disorder. Insurance feels that its medically necessary for someone suffering with depression or anxiety to get therapy to help with these diagnoses. However, if someone is suffering with erectile dysfunction or painful intercourse insurance does not consider therapy medically necessary.
Given that insurance does not cover therapy for sexual health diagnosis, people often have to pay out-of-pocket for therapy. I am always happy to provide people with what is called a super bill that they can attempt to seek reimbursement from their insurance provider. The problems with our insurance system should not keep people from advocating for covering what should be covered.
There are no codes to bill insurance for couple’s therapy. There are codes to bill insurance for family therapy but some insurances don’t even cover family therapy. Family therapy must have several elements to be acceptable to insurance companies. A member of the family must have a medically necessary mental health diagnosis and the therapy must be aimed to decrease the impact of the mental health diagnosis on the family. If a person has depression and I meet with them and their partner to help decrease the impact of that depression on their functioning as a family or a couple that is family therapy. If I am meeting with a couple to address conflict over sexual activity that is couple’s therapy.
The insurance code for individual therapy does allow for someone else to join a session. However, this code cannot be used to bill for ongoing couples’ therapy. It is often helpful to do what is called a collateral session, which means someone I see for one-on-one therapy would bring their partner into a session. In this case the person I have been seeing remains my client and the focuses of any collateral sessions.
Other options for couple’s therapy are employee-based assistance programs or EAPs. Most of these programs allow a fixed number of free sessions that can be couples therapy. Also, many college programs offer low-cost clinics where their students see people as part of their training program. Pacific Lutheran University (https://www.plu.edu/mft/the-couple-and-family-center/) located in Washington is a great example of this type of program.
Having to pay for therapy can be overwhelming and seem unaffordable. However, therapy can also be life changing and help you achieve multiple goals. It doesn’t hurt to ask a therapist about a sliding scale. This is an issue that each therapist handles very differently but most offer some version of it. Clients who at first expresses frustration or concern about the cost often start to remark on how beneficial they feel it is and are no longer concerned about the cost.
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