WHAT IS BPD?
Understanding Insurance Coverage for BPD Treatment
Understanding insurance coverage is an important step when planning for treatment for borderline personality disorder (BPD). Insurance plans can feel confusing—especially when you’re already managing stress. This page explains common terms and shows you how to estimate potential costs so you can make informed decisions about care.
Every Plan is Different
Even two people insured through the same company may have different deductibles, copays, or provider networks. The steps below will help you understand how your own plan works.
Where To Find Your Plan’s Information
Your health insurance company’s online customer portal is a good place to find your plan benefits, progress toward meeting your deductible, and any other resources available through the insurance plan (such as health coaching, educational pamphlets, or a patient advocate).
The portal should also contain a link to your entire plan details (not just the overview), although that document may be very lengthy and difficult to understand if you do not have a background in medicine.
It is often easier to call your insurance company directly. There should be a “Patient Access” or “Customer Service” number on your insurance card. When you call, make sure you have something to write with so you can take down any necessary details.
Questions to Ask Your Insurance Provider
- What is the deductible for my plan? How much of the deductible has already been met / how much remains?
- Do I have out-of-network benefits? If so, what is the deductible? What is the coinsurance once the deductible has been met?
- I / my family member has been recommended for a higher level of care (IOP, PHP, etc). Do we need prior authorization for this service? If so, who should my provider contact? Are there any facilities at this level of care near me that are in-network? Learn more about levels of care >
- What is the copay or coinsurance for this level of care? Does the deductible apply? If the deductible applies, what is the allowed amount for this level of care by this provider / this facility? (This will help you estimate how much you will pay for each office visit or day of treatment until your deductible has been met.)
- Is there any limit on the number of psychotherapy sessions (or days at a higher level of care) covered by this plan? If so, can this be appealed if the services are still medically necessary? How?
- Are psychotherapy sessions limited to a certain duration (i.e. 45 minutes vs 60 minutes)?
- I have reached out to the in-network providers in my area and they are not taking new clients / they do not specialize in my diagnosis. I would like to see an out-of-network provider at in-network rates. Is this possible, and if so, what documentation is required and where do I send it?
- Always make a note of the call reference number and the name of the person you spoke to before you hang up. This will be helpful in filing an appeal if your claim is denied, or following up on previous calls.
Planning Guide
About These Examples
Once you understand your deductible, copay, or coinsurance structure, you can estimate potential costs.
The numbers presented here are examples for educational purposes only. Your actual costs will depend on the specifics of your plan, the provider you see, and many other variables. Only your insurance company can verify your plan details.
Sample Plan Details
In-network deductible: $1,000
Office visit copay: $50
Coinsurance: 90%
Out-of-network deductible: $2,000
Out-of-network coinsurance: 50%
How to Estimate Costs
Deductible ÷ allowed amount =
number of sessions until I meet my deductible
Coinsurance x allowed amount =
how much insurance pays after deductible is met
Scenario One: In-Network Provider With Copay
- Find a provider who is in-network. Confirm CPT codes used by provider (if possible).
- Insurer verifies that the deductible does not apply for those CPT codes, and those are copay visits.
- Insurer verifies you have a standard office visit copay of $50
- Every time you visit your provider, you will pay $50. If you reach your out-of-pocket max, you pay $0.
Scenario Two: In-Network Provider With Deductible
- Find a provider who is in-network. Confirm CPT codes used by provider (if possible).
- Insurer verifies that deductible does apply for these services.
- Ask insurer what the allowed amount (or contracted rate) is for [CPT code] billed by [NPI if you have it, or provider name & education level].
- Insurer verifies the allowed amount for that CPT code is $100.
- You will pay $100 per visit until you meet the deductible. Remember that all approved in-network spending counts towards the deductible, even if you see multiple providers.
- In ten sessions (or fewer), you have met your deductible. After that, you pay $10 per session until you reach your out-of-pocket max, and then you pay $0
Scenario Three: Out-Of-Network Provider
- Find a provider who is out-of-network. Session rate is $200.
- Insurer verifies out-of-network benefits (with/without) the need for prior authoritzation.
- Ask insurer what the allowed amount is for [CPT code] billed by [NPI if you have it, or provider education level].
- Insurer verifies the allowed amount for that CPT code billed by that provider is $100.
- You will pay $200 per visit directly to the out-of-network provider.
- Provider gives you a superbill, which you submit to insurance.
- Insurance counts $100 (the allowed amount) per session towards your out-of-network deductible. The out-of-network deductible does not include the in-network spending you may have already made.
- After 20 (or fewer) sessions, you have met your out-of-network deductible. Your insurance will then reimburse you $50 (50% of the $100 allowed amount) per session, and your out of pocket cost will be $150 per session.
Insurance Resources
A PRACTICAL PERSPECTIVE
Insurance coverage can feel complex, especially when you are focused on getting help. Taking time to understand your plan can reduce uncertainty and help you make informed decisions about care.
If coverage is limited or a provider is out-of-network, ask about reimbursement options, payment plans, or alternative providers within your network.
Understanding your coverage is one step in accessing effective treatment. With clear information, you can plan more confidently.
Key Insurance Terms Explained
Allowed Amount
Claims, Denial, and Approval
If a claim is approved and you have not yet met your deductible, you have to pay your provider directly, but the money you pay counts towards your deductible. If a claim is approved and you have already met your deductible (or the deductible does not apply), the insurance will pay the provider directly, minus any copay or percentage that is your responsibility. Any amount you pay will count towards your out-of-pocket max.
If your claim is denied, you may still have to pay the provider directly, but the money you spend will not count towards your deductible or your out-of-pocket max.
Coinsurance
CPT Code
Deductible
“Deductible Applies” vs. “Deductible Does Not Apply”
If the deductible applies, it means you will have to pay the provider directly in full until you have met your deductible, and then the insurance will begin to cover a portion. If the deductible does not apply, your insurance will pay for a portion (or all) of the service right away.
Diagnostic Code
In-Network (INN) vs. Out-of-Network (OON)
Providers who are not “in-network” with your insurance company are considered “out-of-network.”
Some plans include both INN benefits and OON benefits, meaning you can still be reimbursed for care given by an OON provider. Other health insurance plans only have INN benefits.
If your plan has OON benefits, be aware that they are usually separate from INN benefits. The money you spend in-network does not apply to your out-of-network deductible, and vice versa.
Level of Care
Outpatient: You visit the provider’s office less than twice a week
Intensive Outpatient (IOP): Usually 3+ days a week for a few hours a day
Partial Hospitalization (PHP): 5 days a week but the patient continues to live at home
Inpatient: Short-term hospitalization for a mental health crisis. Inpatient units are monitored by staff 24/7, typically locked, and may include patients who are there involuntarily. Inpatient hospitalization can last as short as one night, or up to a few months, depending on what state you live in and what services are available.
Residential: Long-term treatment where the patient lives in a facility. Residential facilities do not have the same level of monitoring/security as inpatient, and are not equipped to handle acute crises.
Medical Necessity
NPI Number
Out-of-Pocket Max
Patient Advocate
- Act as a “translator” between you and a complicated health system
- Speak to providers on your behalf
- Help you identify available resources
- Help you understand your benefits
Plan Year
Prior Authorization
Superbill
When you see an out-of-network provider, you pay them directly for their services. The provider then gives you a superbill which has all the same information as a claim form, and also confirms you have already paid.
You then submit the superbill to your insurance directly; there is usually an option to do this online through the member portal. From there, your insurer will either apply the amount spent to your out-of-network deductible, or provide you with a partial reimbursement.