Using Insurance to pay for therapy

Who has insurance benefits?

The Canadian Life and Health Insurance Association estimates that 67% of Canadians have extended health care benefits through their workplace, privately held insurance, or through a government support program.  

What do my insurance benefits cover?

What is covered varies from plan to plan.  Plan coverage tends to be broken into two areas Dental Plans, and Extended Health Benefits.  Extended Health plans may cover a wide range of items, but are generally designed to offer coverage for services not included in universal health care (e.g. Alberta Health Care).  These services are typically grouped into sections such as: prescription drugs, hospital room upgrades, specialized nursing, out of country medical care, artificial limbs/prostheses/medical appliances, wheel chairs/walkers, vision care, and Paramedical Services.  Each of these sections tends to have separate application process (e.g. physician referral, prescription, needs assessment, etc...) and funding amounts.  This means that if you use up all of your vision coverage to get a new pair of glasses this does not impact funding available for a hospital room upgrade or a wheelchair. 

Services such as psychologist/mental heath therapist, chiropractors, physiotherapists, massage, podiatrists, osteopaths and optometrists fall under Paramedical Services.  Paramedical Services often draw on one pool of money.  This means that if you use your benefits to see an osteopath, you will have less money remaining for psychology services, or to see a physiotherapist.

What about my health spending account?

Some businesses, Non-Governmental Organizations (NGOS)/Not-for-Profits, and many government agencies also offer their employees a Health Spending Account (HSA).  The idea behind an HSA is to allow employees greater flexibility to choose where they spend their benefits.  For example, one person chooses to spend a portion of their HSA money on a gym club membership, another uses their HSA to allow for extra psychology sessions beyond what is covered under their Extended Health Benefits insurance coverage.  Generally HSA funds are easier to access than insurance benefits, and often only require you to submit proof of payment to obtain reimbursement.

What about if I am on, or will be on, disability Insurance?

Services provided under disability insurance are typically up to the discretion of your insurance provider's Case Manager/Return-to-Work Specialist.  Most often the goal of the case manager is to get you healthy enough so that you can return to work. 

Case managers have a significant amount of discretion regarding what type of services, how much service, or when service is offered.  Case managers often rely on medical reports to make determinations about what services to offer and if they will pay for those services.  Once a service is in place, such seeing a psychologist or physiotherapist, the case manager relies on reports from the professional to determine if services need to be continued, or if additional or alternate services should be offered.  Sometimes clients are already seeing a psychologist before they go on disability.  If the client requests it, the case manager may be willing to set up a contract to pay for ongoing sessions with the mental health therapist.

Some case managers are very proactive and will encourage their clients to begin treatment as soon as it is advisable.  Other case managers wait until the client asks (sometimes repeatedly) for a particular service, or because the employer is making inquires regarding the client's progress towards returning to work.  Firefly Counselling has worked with clients who received services immediately after being approved for disability, and with clients who were not referred for (any) treatment for 6-9 months, but were now within a month of their return-to-work date, and their case manager wanted to get them ready to be back at work. 

Needless to say, clients who advocate to receive services as soon as possible, have the greatest chance for recovery.  Asking for the desired service such as counselling, therapy, or an assessment to see what is needful, can often reduce the wait times to beginning treatment, and get you back to work in a timely and successful manner.

Can you direct bill my insurer?

Sometimes...  All of our clinicians can direct bill Alberta Blue Cross, Alberta School Employee Benefit Plan (ASEBP) (Teachers and School Support Staff) and Green Shield.  

Some of our clinicians can direct bill Medavie Blue Cross (RCMP, Canadian Forces, Military Veterans) and Criterion Group (Alberta Physicians Association).  These insurers give approved psychologists and mental health therapists an internet portal to use, so we can do the invoicing and provide you with a receipt at the end of the session.

Some of our clinicians can direct bill for clients with Treaty Status who are covered by First Nations Non-Insured Health Benefits (INAC).  Firefly Counselling may also direct bill for individuals who have attended a Residential School listed in the 2006 Indian Residential Schools Settlement, the client's spouse or partner, or those raised in the household of a former Indian Residential School student, or any relation who has experienced the effects of inter-generational trauma associated with a family member's time as an Indian Residential School. 

Some of our clinicians can also direct bill other insurance providers such as SunLife, Chamber of Commerce, Great West Life, CINUP, COWAN, First Canadian, iAFinancial Group, Johnson and Johnston Group, Maximum Benefit and Desjardins

Clients without 100% coverage for their direct billed service will need to pay the balance outstanding at the time of service. 

What kind of therapists can direct bill insurers?

Which type of clinician is allowed to direct bill is entirely at the discretion of the insurance provider.  We do not know why the insurance company reimburses clients for services when the client submit the invoice, but denies clinicians a direct billing option. Our clinicians are happy to direct bill if the insurance company give us the opportunity to do so.  When we cannot direct bill we provide the client with a receipt they can use to claim reimbursement from their insurance provider.

Not every insurer covers every type of mental health therapist.  For example, Alberta Blue Cross will cover and allow direct billing for services provided by psychologists, social workers, and clinical social workers.  They do not cover provisional psychologists.  SunLife will cover psychologists and social workers, but only allows psychologists to direct bill.  Manulife only covers psychologists, but does not allow psychologists to direct bill.

Most insurance providers in Alberta will not cover master's students, psychotherapists, hypnotherapists, marriage and family therapist, occupational therapists (working as mental health therapists) or nurses (working as mental health therapists) unless they have an additional designation as a psychologist or, in some cases, a masters level social worker.

I was in a car accident and my lawyer said I need to "see someone".  How is that paid for?

If you have insurance benefits that include mental health coverage you may use those insurance benefits to seek treatment.  

Alternately, all Albertans have mental health coverage through Alberta Health Services. To access this coverage you can call Health Link (811) and ask for a referral to a mental health specialist.  Health Link will set up an intake telephone interview for you with the mental health office.  Based on that interview you will be matched with a mental health therapist.  Depending on availability you may have your first appointment within a week to several months of your original phone call.  Return appointments are dependent on the therapists caseload and may vary between weekly, bi-weekly or monthly.  Mental health therapists who work for Alberta Health services may be Occupational Health Therapists, two-year Nursing Diplomas, four-year Nursing Degrees, Registered Psychiatric Nurses, Social Workers, Clinical Social Workers, Certified Canadian Counsellors, Provisional Psychologists or Psychologists.  Alberta Health Services generally does not support their staff to write reports for  third parties (such as lawyers) as this reduce the amount of time these clinicians have to provide client services.

Sometimes lawyers may offer to pay the cost of therapy.  Firefly Counselling and Consulting can direct bill other third party payors (such as lawyers, disability insurance providers, employer agencies/organizations...) once we have a contract in place with the third party payor.  

Lawyers, disability case managers, and HR staff (etc.) will sometimes refer clients directly to us, or you may pick a psychologist and then ask your lawyer, disability case manager, or HR staff member, to set up a contract with us for payment.  Once a contract is in place we will send the invoices directly to your third party payor.  In return, the third party payor will ask for assessment, progress and final reports.  You will be asked to consent to release this information.  

Ultimately, lawyers will deduct the cost of the therapy from any settlement you receive.  Disability case managers cover the costs as part of insurance premiums and HR staff have costs underwritten by disability insurance companies.

If you wish sessions to be direct billed to a third party, please make sure the contract is in place first.  Sessions that occur prior to the contract being set will not be covered by the contract.

What do I need to do to use my insurance coverage?

For Blue Cross (provincial and Medavie) coverage we need the following information: your name (first and last) as known by your insurer, insurance number (including the number after the dash if there is one), your group number, and date of birth.

For ASEBP we need: your name (first and last) as known by your insurer, insurance number, group number, and date of birth.

For Green Shield we need the following information:  your name (first and last) as known by your insurer, carrier (Green Shield or SSQ Financial Group), and plan member ID.

For Criterion Group we need your name (first and last) as known by your insurer, and your plan number ID.  As Criterion Group does not cover the full cost of service there may be an additional direct billing charge.

For INAC we need your name as written on your Treaty Status Card, Treaty Status number, current address, current phone number, date of birth.

For the Indian Residential Schools Resolution Health Supports Program we need: your legal name, your current address, current phone number, date of birth, the dates you attended a residential school and the name of the Residential School.   If you were not the attendee, then we need the name (on the school record) of the spouse or relation who attended the Residential School, name of the school, and dates of attendance.

For all other insurers you will need to ask if your insurance provider is willing to set up a direct billing contract.  If they are, please provide them with the contact information for Firefly Counselling and your therapists name (if known).  Please provide us with your Case Manager's (or equivalent contact) name and contact information at the insurance company.  We will talk with each other to establish a treatment contact delineating treatment goals, length of treatment, treatment timelines, and reporting requirements.  Once the contract is in place we will direct bill the insurer at the end of each month.  Generally insurers will not cover sessions that occur prior to the contract start date, or those that do not meet the contract terms (such as no-shows, late cancels, or for matters not relating to the reason the insurance provider is involved).  In most cases services provided under contract will also have reporting requirements.  The reporting requirements vary from insurer to insurer, so please speak with your Case Manager or therapist to understand what information will be released.

Insurance providers often decline to cover missed sessions.  Missed sessions must be paid for by the client unless the therapist chooses to waive the fee.

Is there anything I should know when using insurance coverage?

It is important to know how much coverage you have.  Your insurance provider can give you this information.  Questions to ask are:

  1. What types of clinicians (e.g. psychologists, social workers, Certified Canadian Counsellor...) do I have coverage for?
  2. Is there a maximum coverage amount (per year/lifetime)?  If so, what is it?
  3. When does my insurance coverage 'roll-over' or 'renew'?
  4. If I use up all my sessions/coverage but need more therapy what happens?
  5. If I am on disability - What information will be provided in the reports?  Can I get a copy?  How do I get a copy?
  6. If I am on disability - Do I have to go to the psychologist/therapist my case manager sends me too, or can you ask to work with someone of my choice?