What Your Therapist Wishes You Knew About Insurance (Part 4 of 4): When Insurance Isn't an Option — Other Ways to Make Therapy Work
This is Part 3 of a 4-part series on using insurance for therapy.
Part 2: In-Network vs Out-of-Network — What's the Difference?
Part 3: Why You Might Get a Surprise Bill — Even With Insurance
Part 4: When Insurance Isn't an Option — Other Ways to Make Therapy Work you are here
We've covered a lot of ground in this series: why therapy billing is complicated, how in-network and out-of-network options work, and why surprise bills happen even when you've done everything right.
This final part is for anyone who has reached the conclusion that insurance, for whatever reason, isn't a workable path for them right now. Maybe you don't have coverage. Maybe your plan's mental health benefits are too limited to be useful. Maybe you're concerned about having a diagnosis on your record. Maybe the in-network options available to you just aren't the right fit.
If that's you, you have more options than you might think.
Sliding Scale Fees
A sliding scale is a pricing structure where your session fee is adjusted based on your income and financial situation rather than being a fixed rate.
At Mindful Kindness Counseling, I offer sliding scale fees for clients. This is a deliberate part of how I run my practice, because cost shouldn't be the reason someone doesn't get mental health support.
You don’t have to do anything to show that you “qualify” for a sliding scale. Anyone who comes to therapy with me can use the sliding scale. My current full rate is $150/session. My sliding scale starts at $90 (which is 60% of the full rate) and goes up to the $150 rate. Clients tell me where they can comfortably sit on that scale, and that’s what they pay. I’m also open to negotiating further when it’s necessary. Don’t worry about asking me about it; I’ve got the sliding scale as an option and it’s there for your use.
I know that talking about money can feel awkward, especially in a therapeutic context, but it genuinely isn't a difficult conversation on my end. Talking through the fee structure is an important part of beginning a therapeutic relationship. We can be open and honest about sticky subjects right from the beginning.
Out-of-Network Reimbursement (Superbills)
Even if you're paying out of pocket, you may be able to recover a portion of the cost through your insurance's out-of-network benefits.
As covered in Part 2, a superbill is an itemized receipt I can provide after each session that contains everything your insurance needs to process a reimbursement claim. You pay me directly for your session, submit the superbill to your insurer, and they reimburse you based on your plan's out-of-network coverage.
This option is worth exploring even if you're not sure your plan covers out-of-network care. Call the member services number on your insurance card and ask: "Do I have out-of-network mental health benefits, and what is my reimbursement rate after my deductible?" Some clients are genuinely surprised by what their plan covers once they ask.
Using an HSA or FSA
If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA) through your employer, therapy sessions with a licensed therapist are typically an eligible expense. This means you can pay for sessions with pre-tax dollars — which effectively reduces your cost depending on your tax bracket.
Check with your HSA or FSA administrator to confirm eligibility, but in most cases mental health therapy qualifies without issue.
How to Have the Money Conversation With Your Therapist
A lot of people avoid asking about cost because they're worried it will be awkward or that their therapist will judge them for it. I want to put that concern to rest directly: with me, it will not be awkward, and you will not be judged. (Side note: if you have this conversation with a therapist and you do feel judged, that might not be the right relationship for you.)
Therapists who offer sliding scale fees expect the conversation. It's part of the intake process, and a supportive therapist will handle it matter-of-factly and without making you feel uncomfortable for asking. Here's what you can say:
"I'm really interested in working together, but I want to be upfront that the standard rate is a stretch for me financially. Do you have any flexibility, or do you offer a sliding scale?"
You don't need to justify it, over-explain, or apologize. You don’t need to show me pay stubs or go too far into your financial situation. The sliding scale is an option so that you can use it freely.
The Most Important Thing
After four parts covering the mechanics of insurance, billing, and payment options, I want to end with the thing that matters most:
Please don't let cost be the reason you don't get help.
I know that's easier said than done, money is real, capitalism is very real, and so are the limits of what people can afford. But there are more options available than most people realize, and the conversation about cost is always worth having before you conclude that therapy isn't financially possible for you.
If you're in San Antonio or anywhere in Texas and you're thinking about starting therapy, I'd love to connect. The free 15-minute consultation call is a no-pressure way to ask questions, talk through what payment might look like, and see if we're a good fit.
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Bonnie Scott is a Licensed Professional Counselor-Supervisor (LPC-S) in San Antonio, TX. She offers individual therapy, couples counseling, and LGBTQ+ affirming care in person and via telehealth throughout Texas.
