Using Insurance or Paying Yourself for Psychiatric Care

What is the real difference between the two?

Neither choice is right for everyone, and the choice is mostly about three things: cost, rules and information. The table below sets them side by side. All of our actual rates are on one page, so this guide compares the trade-offs instead of amounts.

How does my deductible change the math?

A deductible is what you pay before your plan starts to pay. If you have not met yours, you may pay the plan's full allowed amount for a visit. Once you have met it, you usually pay only a copay or coinsurance. So the same plan can cost very different amounts in January and in November.

To compare fairly, get two numbers from your plan and set them beside the self-pay rate on our insurance and fees page. Then think about the whole year, not just the first visit, since follow-up visits may be part of your care.

• What is the allowed amount for this visit under my plan, and how much of my deductible is left?
• What will my copay or coinsurance be after the deductible is met?
• If I pay outside my insurance, does that money count toward my deductible or out-of-pocket limit?

Does paying myself make my care more private?

Somewhat, but it does not make your care invisible. When you use insurance, the clinic gives your plan information about you so the plan will pay for your services. Our Notice of Privacy Practices says that if you pay out of pocket in full for a service, you can ask us not to share that information with your health insurer for payment or our operations, and we will say yes unless a law requires us to share it.

Paying yourself does not remove the health record. A clinic still keeps a record of your care, and the record is protected whichever way you pay. If privacy is the main reason you are weighing this, say so when you contact us, so the request is clear before the visit. Our guide on whether psychiatric care is private covers the wider question.

What happens if the provider is out of network?

It depends on your plan type. An HMO generally will not cover out-of-network care except in an emergency. A PPO lets you see providers outside the network without a referral, at an additional cost. Asking your plan first can save you from a bill you did not plan for, and our guide to checking your benefits has the exact questions.

If you are thinking of paying the clinic yourself and then sending paperwork to your plan for out-of-network reimbursement, ask your plan whether it allows this, and ask us what paperwork we can provide. Do not assume the answer either way.

What is a Good Faith Estimate?

It is a right under federal rules for people who do not have insurance or are not using it. Usually, your provider must give you an estimate of expected charges if you ask for one or schedule care at least 3 business days in advance. It should list items and services with expected charges, and it can be given on paper or by email.

An estimate covers one provider or facility, so it may not include services from anyone else or services scheduled separately. With psychiatric care, that means it helps to ask whether follow-up visits are included. You can ask for an estimate when you request an appointment or call.

How does the sliding scale work here?

DanShalom Behavioral Clinic offers a sliding scale. This guide does not set out the details, so ask us when you request an appointment or call. Useful questions are how the scale works, whether it may apply to you, and what you would need to share.

Please ask before your first visit, not after a bill arrives, so that you can compare it with your other options while you are still deciding.

What about the cost of medication?

Any visit estimate is separate from what a pharmacy charges, whether you use insurance for visits or not. If medication becomes part of your care, ask your plan about prescription coverage, and tell your prescriber if cost is a concern. A lower-cost generic or a pharmacy or manufacturer program may be an option.

Do not cut pills, skip doses or take a medication only when you feel bad to save money, because that can make your condition worse. Talk with your prescriber first. Medication decisions are made after an evaluation, not every medication can be prescribed at every kind of visit, and some may require an in-person visit. We explain what applies to you, and medication management describes how follow-up works.

How do I decide, and what if I am still unsure?

Using insurance often makes sense if the clinic is in your network, your deductible is mostly met, or you expect regular visits. Paying yourself may suit you if your deductible is high and unlikely to be met, you have no coverage in the state where you will be during visits, or keeping a service away from your insurer matters to you. A sliding-scale conversation may change the picture for either case.

You do not need to work this out alone. We check coverage before the first visit and can go through what we find, whether you plan to come to the Sugar Land office or use video from Texas, Idaho, Arizona or Maryland. If you have coverage through a government program, ask us before choosing to pay yourself, because different rules may apply.

Cost should not delay urgent help. If you or someone you know is in crisis, call or text 988, or call 911 if there is immediate danger. DanShalom Behavioral Clinic is not an emergency service.