Navigating Deductibles and Co-pays for Commercial Plans like IBX, Aetna & United

Felix A. Perez, LCSW
Oct 31
4 min read

Updated: Nov 5

By Felix A. Perez, LCSW - CEO & Practice Owner

Make it make sense.

Navigating the world of insurance can feel like a nightmare. Deductibles, co-pays, coinsurance, out of pocket max…all so complicated! This blog helps potential clients better understand what they can expect when they use commercial insurance at Perez Therapy. Accessing care shouldn't be difficult, but health care is a complex system of credentialing, billing, coverage, and reimbursements. As we accept more in-network plans, like Independence Blue Cross (IBX), Aetna and United, prospective clients will likely face these questions as they attempt to use their insurance.

The Prescreening Process

All clients complete a prescreening as part of the referral process. The prescreening form can be completed by the client or referral source online. Alternatively, people can call our office to complete the prescreening. You can upload your health insurance card to the client portal or send it to us via email at Info@PerezTherapyLLC.com.

In-Network vs. Out-of-Network Benefits

Health insurance plans prefer to manage each in-network provider individually. Not all providers accept all insurance plans, and it can never be assumed that you can use your benefits until you have them verified by your provider.

Our in-network plans are listed on our fees & insurance page of our website. In addition to Independence Blue Cross, Aetna and United, we're in the credentialing phase with Cigna/Evernorth, Highmark. We also anticipate that some providers will be in-network with Medicare. We hope to be in-network with most commercial plans by the end of 2025.

What are tiered in-network providers?

Some health plans have tiered providers for in-network services. For instance, in Philadelphia, employees of Jefferson Health have tiered provider plans. Tier 1 providers are those that are in the Jefferson Health system. Lower tier providers are then in-network credentialed providers with Jefferson Health Plans/Health Partners Plans. In 2023, Jefferson Health purchased Health Partners Plans and began managing Medicaid, CHIP, as well as commercial plans for employees of Jefferson Health and Thomas Jefferson University. Copays and deductibles are often higher for providers who are not Tier 1 providers.

Is there a copay?

Generally yes, there is a copay, but it can differ based on the specific plan you have, often negotiated through your employer, if you have benefits through a job or family member. Ideally, you have a flat copay for services, like $20 to $60 dollars per visit.

What is a deductible?

A deductible is the amount that you are minimally required to spend out of pocket before you can use your insurance benefits. Deductibles frequently range from a few hundred to a few thousand dollars. So a deductible of $3,200 will need to be paid by the consumer first before insurance can be used. This means that if you want to receive therapy and use your benefits, you first have to pay that $3,200 down for your insurance year (and verify if it's on the calendar year).

How do I pay down my deductible?

If you have a deductible, it may need to be paid down before you can pay a lower copay or a co-insurance (we’ll get to that later). But sometimes, health plans allow in-network mental health services to be received, and the consumer is charged a co-pay. Other times, you have to pay down the $3,200 deductible at the full rate of the session before you can use your health benefits.

If you receive other medical services from another provider, that will help pay down your deductible. Most often, all services received in the coverage year count toward the deductible. Just be sure to check that your health plan hasn't created a separate deductible for mental health benefits (I've seen this once before).

For example, if your deductible is $3,200, and your provider's rate for therapy is $120, you have to attend about 26 sessions in a year in order for your benefits to start kicking in. Then, your insurance will begin providing coverage. It should be noted. When the deductible is this high, unless you, or someone else in your family, has other medical expenses, you will rely on your mental health payments to meet your deductible. You won't start receiving any coverage until the deductible is met. If they attend a whole year of therapy on a biweekly basis.

People who receive therapy on a weekly basis will meet their deductible sooner than those who attend biweekly sessions. After you've met your deductible, you might be covered 100%, or have a co-insurance payment at a lower percentage.

What is co-insurance?

Co-insurance is the percent the insurance will cover of the services received after you've met your deductible. Now, you've paid down your $3,200 deductible, from the example above. The insurance has a percent that they will cover of the service and split the cost with you. For example, if your co-insurance is 50%, the $120 session would have be covered, making the service only $60.

What's an out of pocket max?

This is the maximum that you will have to pay out of pocket for health care services in an annual coverage period. This number is often much larger than the deductible. In our example of the $3,200 deductible, the out of pocket maximum could be $6,400, double the amount. After paying the out of pocket maximum, generally all in-network services are fully covered, unless there are any stated caps for services in your plan (meaning that your plan will only pay for a certain amount of services within the coverage year).