Insurance and Couples Counseling

Many people have questions about the inclusion of marital and couples therapy as a benefit covered through health insurance.  Although most EAP programs (Employee Assistance Programs) provide a benefit for this kind of therapy, most insurance companies do not.  There is a lot of confusion around this subject perpetuated by insurance companies, therapists, and the public.  For counseling to be covered by insurance, it must meet the criteria for “medical necessity” by the insurance company.  Although marketing materials and insurance company representatives  will often suggest that couples and marital counseling is covered, that does not hold up in the billing and claims process.  Couples counseling is only covered under the billing code of “family therapy”, billing code 90847, when the focus of the therapy is on treating a documented psychiatric diagnosis and that the clients’ symptoms meet “medical necessity” criteria, which involve severity, duration, and adherence to the DSM-5 (Diagnostic and Statistical Manual, which defines psychiatric diagnoses). Most couples therapy focuses on communication and conflict management, not a psychiatric diagnosis. It is commonplace for therapists to write up billing claims to meet these criteria to get reimbursed by the insurance company, even if the service does not meet medical necessity criteria.  This is insurance fraud and penalties can be incurred by the therapist and the client.  While marital and couples counseling is necessary and useful for most couples at some point in their relationship, it does not normally fit medical necessity criteria, and the therapist faces a professional risk by making claims through insurance. The good news is that most flexible spending plans and health savings accounts provided by employers do cover couples counseling.