How to Use Out-of-Network Benefits for Therapy in California (Superbills, Reimbursement, and What to Ask)

By Christina Mathieson, LMFT #115093, founder of My Mental Climb.

TL;DR. If your therapist is private-pay and you have a PPO plan, you can often still use your insurance through out-of-network benefits. You pay the full fee at the time of the session, your therapist gives you a superbill (an itemized receipt with the codes your insurer needs), you submit it, and your plan reimburses a percentage of the fee, commonly 50 to 70 percent, after you have met your out-of-network deductible. HMOs like Kaiser generally do not reimburse out-of-network. This post covers how the process works, the one catch most people miss, and the exact questions to ask your plan before you book.

"Do you take my insurance?" is usually the first question a prospective client asks, and the answer, for most good specialty therapists in California, is some version of "not directly, but here is how your insurance can still help." That answer sounds like a brush-off, but it is not. It describes a real, widely used pathway called out-of-network benefits, and if you have a PPO plan, it may cover a meaningful share of the cost of seeing a therapist who is not in your insurance network.

Most people have never had this explained clearly, so they assume "out-of-network" means "you pay everything," when it often does not. Here is the whole picture.

The three ways therapy gets paid for

Almost every therapy arrangement in California falls into one of three buckets, and knowing which one you are in changes everything about cost.

• In-network. Your therapist has a contract with your insurance company. You pay a copay (often $20 to $50), the plan pays the rest at a negotiated rate, and the therapist bills the insurer directly. Simple, but it limits you to the clinicians who have that contract.
• Out-of-network. Your therapist has no contract with your insurer, but your plan still reimburses part of the cost. You pay the therapist's full fee up front, then submit a claim (a superbill) and your plan pays you back a percentage after your out-of-network deductible is met.
• Private pay with no insurance involved. You pay the full fee and do not involve insurance at all. Some people choose this deliberately, for reasons I will get to below.

Out-of-network is the one that gets misunderstood, because it sits in the middle. You are paying out of pocket at the time of service, which feels like private pay, but you may get a large portion of it back, which makes the real cost much closer to in-network than the sticker price suggests.

How out-of-network reimbursement works

The mechanics are more straightforward than they sound. The sequence looks like this:

1. You pay your therapist's full fee at the time of the session. For a licensed therapist in California, that is typically $175 to $300, and in the Bay Area it can reach $400. With a supervised associate the fee is lower.
2. Your therapist gives you a superbill. This is an itemized receipt, usually generated monthly, that contains everything your insurer needs to process a claim: the dates of service, the service codes (CPT codes, more on those below), a diagnosis code, and the therapist's license and NPI number.
3. You submit the superbill to your insurance company. Most PPO plans let you do this through an online portal, a mobile app, or a mailed claim form.
4. Your plan reimburses you a percentage after your deductible. Once you have met your out-of-network deductible for the year, your plan pays you back a share of each session, commonly 50 to 70 percent, though this varies widely and some plans reimburse against an "allowed amount" that is lower than your therapist's actual fee.

That last detail matters before you count on a number. Some plans reimburse a percentage of what you actually paid. Others reimburse a percentage of their own "allowed amount" or "usual and customary rate," which can be lower than your therapist charges. Two people with the same nominal "70 percent out-of-network" benefit can get back quite different amounts depending on how their plan defines the base it pays against. None of this is a reason to skip out-of-network. It just means asking the specific questions below before you assume a figure.

What a superbill is, and the one catch most people miss

A superbill is not a bill you owe. It is a receipt for services already paid, formatted so your insurer can process it as an out-of-network claim. Your therapist produces it; you submit it.

The catch is the diagnosis. To reimburse any mental health claim, in-network or out-of-network, an insurer requires a mental health diagnosis code. That means your therapist has to assign you a diagnosis (an ICD-10 code such as an adjustment disorder, an anxiety disorder, or a depressive disorder), and that diagnosis becomes part of your medical record and is shared with your insurance company as part of the claim.

There is a related wrinkle here. Sometimes what brings you in is not a diagnosable disorder. It might be relationship distress, a life transition, or a hard stretch that does not rise to the level of a depressive or anxiety diagnosis. In those cases the closest code is what is called a Z code (older systems called these V codes), such as Z63.0 for distress in a relationship with a partner. Many plans do not reimburse Z-code claims, because they do not treat them as a medically necessary mental health condition. This comes up most in couples work, which is one reason couples therapy is so often full private pay. If what brings you in is genuine but not clinically severe, ask your therapist how they would code it, and confirm your plan reimburses that code before you count on it.

For most people this is a non-issue, and the reimbursement is well worth it. For some, it is a reason to choose full private pay with no insurance involved: no diagnosis is assigned, nothing is shared with an insurer, and the therapy stays entirely off any insurance record. Neither choice is right or wrong. It is a genuine tradeoff, and a good therapist will talk it through with you rather than assume.

The CPT codes that show up on a superbill

Insurers process claims by code, so a few numbers are worth recognizing when you see them on a superbill:

• 90791 is the initial diagnostic evaluation (your intake session).
• 90834 is a roughly 45-minute individual psychotherapy session.
• 90837 is a roughly 55-minute individual psychotherapy session.
• 90847 is family or couples therapy with the patient present, which is how couples sessions are typically coded.

When you call your insurer to ask about benefits (next section), quoting the actual code you will be billed under gets you a far more accurate answer than asking about "therapy" in the abstract.

How to check your out-of-network benefits before you book

This is the part that saves people from unpleasant surprises. Before your first paid session, call the member services number on the back of your insurance card and ask these questions. It takes about ten minutes.

• "Do I have out-of-network outpatient mental health benefits?" This is the threshold question. If the answer is no, out-of-network reimbursement is off the table and private pay is your route.
• "What is my out-of-network deductible, and how much of it have I met this year?" You pay full fee until this is met, so this tells you when reimbursement kicks in.
• "After the deductible, what percentage do you reimburse for CPT code 90837?" (Or 90847 for couples.) Ask about the specific code you will be billed under.
• "Do you reimburse based on the amount I paid, or an allowed amount? If an allowed amount, what is it for this code in my area?" This is the question that reveals the real number.
• "How do I submit a superbill, and is there a deadline to file each claim?" Some plans have filing windows.

If calling is not your thing, some California practices, including ours, partner with a service called Mentaya that checks your out-of-network benefits in real time when you enter your plan details. You can see your estimated deductible and reimbursement rate in about a minute without a phone call. We link to it from our billing and insurance page.

PPO, HMO, and EAP: which plans reimburse

Not every plan type participates in out-of-network reimbursement, and this is the fastest way to know where you stand.

• PPO plans (Anthem, Blue Shield, Aetna, Cigna, UnitedHealthcare, and similar) almost always include out-of-network benefits. This is the plan type where the superbill pathway works.
• HMO plans, including Kaiser, generally do not reimburse out-of-network care at all. With an HMO, you are typically limited to in-network providers, and a private-pay therapist will be full out-of-pocket. There are narrow exceptions when the plan's own network cannot provide timely care (see the parity section below).
• Employer mental health programs (EAPs) like Lyra, Spring Health, and Modern Health are a separate category. They cover a set number of sessions directly, outside the superbill process. They work differently from the out-of-network pathway this post is about. If your workplace offers one, your HR team can tell you what is included.

California's parity law, and the network-adequacy angle worth knowing

California has one of the strongest mental health parity laws in the country. Under the California Mental Health Parity Act as amended by SB 855 (in effect since 2021), commercial health plans must cover the medically necessary treatment of all mental health and substance use conditions at the same level they cover physical health conditions. In plain terms, a plan cannot give you worse coverage for therapy than it gives you for a comparable medical visit.

Parity law also requires plans to maintain an adequate network of mental health providers. When a plan cannot offer you a suitable in-network provider within a reasonable time and distance, it may be required to arrange out-of-network care at your in-network cost-sharing level. If you have called in-network therapists for weeks and none have openings or the right specialty, that is not just bad luck; it can be a network-adequacy issue your plan has an obligation to resolve. The Department of Managed Health Care, which enforces this law, has a consumer help process for exactly these situations. It is worth knowing that the leverage exists.

Is out-of-network worth it? The real math

Here is a realistic example, using round numbers, to show why out-of-network changes the picture. Say your therapist's fee is $200 per session, your out-of-network deductible is $1,000, and your plan reimburses 60 percent of the fee after the deductible.

For the first several sessions, you are paying $200 and getting nothing back while you meet the deductible. Once you have paid $1,000 out of pocket (five sessions at this fee), reimbursement begins, and from that point each $200 session effectively costs you about $80 after the $120 you get back. Over a year of roughly weekly therapy, your effective per-session cost comes out well below the sticker price, and much closer to what an in-network copay arrangement would have cost, while letting you see a specialist you chose rather than whoever happened to be in-network.

Whether that math works for you depends on your specific deductible, your reimbursement rate, and how long you expect to be in therapy. The point is that "out-of-network" is not a synonym for "unaffordable." For many PPO members it is the difference between the sticker price and roughly a third of it.

If out-of-network still does not pencil out, ask about a sliding scale. Many California practices, including ours, offer sliding-scale spots and lower associate rates, and a good therapist would rather find a workable fee than lose a fit over cost.

What we offer

My Mental Climb is a California telehealth practice, and like most specialty practices we are private pay rather than in-network. We make the out-of-network pathway as easy as we can. We provide monthly superbills for PPO out-of-network reimbursement, and we partner with Mentaya so you can check your real-time benefits before you commit. Sliding-scale spots and lower associate rates are there when the math still does not work. The full breakdown lives on our cost of therapy in California and billing and insurance pages, and every self-pay client receives a Good Faith Estimate under the federal No Surprises Act.

If you want help figuring out what therapy would cost you after benefits, that is one of the things our free 15-minute consult is for. You can book a consult with our intake coordinator, who will talk through fit, match you with the right clinician, and give you a clear sense of cost before you commit to anything. The goal is for money to be the thing you understand going in, not the surprise you discover later.

Last clinically reviewed: August 1, 2026 by Christina Mathieson, LMFT #115093.