Your Relationship Isn’t a Diagnosis: Why Insurance Rejects True Couples Therapy

According to Dr. John Gottman, couples wait an average of six years before they make the decision to seek out couples therapy. For many individuals, couples therapy can serve as a lifeline by providing expert guidance as well as the opportunity to build new skills, both directly impacting how you navigate your relationship and determining its overall health.

Being motivated to explore therapy with your partner can be a great first step in creating lasting positive change. Searching for a provider that you both feel comfortable working with can be an exciting part of the process. I’m honored when prospective clients express interest in working together and choose to schedule a 15-minute Consultation Call. One of the many questions that often gets brought up during a call is whether insurance will cover the expenses related to couples therapy. 

Well, that’s a great question! Allow me to provide a bit of (concise and minimally boring) insight.

The Medical vs. Relational Model

Over the years, mental health coverage has undergone significant changes, including the acknowledgement of the importance of mental health. While this is true, insurance still operates under a medical model rather than a broader holistic or relational lens. This means that health coverage only extends to services that are considered to be “medically necessary”. Otherwise deemed essential to “the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms”, as defined by the National Association of Insurance Commissioners.

This approach emphasizes a focus on pathology, diagnosing and treatment, rather than focusing on an individual’s overall emotional wellbeing. This is the core of the medical model. To utilize insurance coverage for the cost of therapy sessions, three specific requirements must be met to justify medical necessity for your treatment:

1. There must be an identified client

2. The identified client must meet criteria for a behavioral health diagnosis as outlined in the DSM-5-TR/ICD-11

3. An evidenced-based treatment directly serving the client and diagnosis must be used

The structure of individual therapy fits well into this model. For example: if:

‍ ‍1. An individual client who is struggling with symptoms as a result of trauma

2. Meets criteria for a diagnosis of Post-Traumatic Stress Disorder

3. An evidence-based treatment, such as EMDR, can be used in therapy sessions to target presenting concerns 

Why does this same formula not work for couples therapy?

Traditional couples therapy doesn’t fit neatly into the medical model that insurance companies require. In true relational work, there is no such thing as one identified client. The relationship itself is the client. Rather than focusing on one person’s symptoms or diagnosis, the therapeutic work centers on the interactions between partners by improving communication, navigating conflict, rebuilding emotional safety, and fostering deeper connection and shared growth. Simply put, the issue here is that insurance companies do not yet recognize the relationship as a legitimate client. As a result, relational issues alone rarely meet their definition of “medical necessity”.

Why does my insurance say they cover couples/family therapy?

Although there are medical billing (CPT) codes representing Family and Couples psychotherapy services, insurance will not provide coverage unless documentation can clearly support individual treatment of the identified client. This means the identified client, Partner A, must meet criteria for a mental health diagnosis during an individual assessment and be the sole focus of treatment thereafter. 

Following an individual intake, a treatment plan would be developed with focus on helping Partner A reduce and manage symptoms related to their identified diagnosis. While the use of CPT codes (such as 90847 and 90846) would allow us to include Partner B within future sessions, treatment would be limited and solely centered around addressing Partner A’s diagnosis and progress. In this case, due to operating within the medical model, treatment is only justified for Partner A. This prevents both partners from being equal participants in therapy and focusing on what really matters for the sake of the relationship. This is not true couples work- it’s individual therapy with additional family support. 

Why are codes and diagnosis important?

As an in-network provider, I hold a legal and ethical obligation to submit accurate CPT codes and diagnosis for all claims submitted to insurance. If insurance claims fail to accurately represent the type of treatment conducted, such as conducting therapy to address common relationship issues under the guise of individual therapy, this is considered fraudulent. The misunderstanding of coverage limitations can result in recoupment of fees by your insurance provider and being on the receiving end of a hefty bill for services already rendered. 

Are there affordable alternatives?

While couples therapy is a valuable investment in your relationship, it’s understandable if you’re also looking to prioritize affordability. Being able to remain in budget will allow both you and your partner to fully commit to the work your relationship deserves without the added financial pressure. Depending on your situation, there are several options worth exploring.

Self-pay: For clients who wish to keep things simple and opt for a self-pay rate, most therapists make this option easy to choose. My current rate for Couples Therapy is $185/hr. This rate remains the same across all session types and extends to both in-person and virtual session formats. Your relationship embodies its own uniqueness. By choosing to self-pay, we’re able to tailor sessions around both partners and support your relationship in a way that’s flexible, collaborative, and grounded in what actually works for you. 

Associate level providers: For those seeking the expertise of a systemically trained clinician but with a budget-friendly fee, finding a Licensed Marriage and Family Therapist Associate may be what you’re looking for. These provisionally licensed professionals provide quality, evidenced-based care at lower rates than fully-licensed professionals. These clinicians are highly trained in family systems and have had a substantial amount of direct-contact experience with couples and families prior to post-grad program completion.

Employee Assistance Programs:Many employers offer EAP benefits to serve employees and their families. Depending on the benefits package, this can include a number of sponsored therapy sessions which can be used for the treatment of couples. Therapist Brittany Rae & Assoc. is currently a part of SpringHelath, Provider’s Direct, Sana Benefits and ModernHealth EAP networks for this very reason! Employee Assistance Programs serve a variety of employers, from start-ups to Fortune 500 corporations. To find out if your job offers an Employee Assistance Program, check your employee handbook or contact your Human Resources department

Sliding scale: In efforts to make services equitable and accessible, many clinicians offer a fee structure that allows for the adjustment of session rates based on a client’s income, family size, or financial situation. We call this an Income-based Sliding Scale. A couple of great and reputable directories for locating multiple providers with these offerings is OpenPathCollective.com  and InclusiveTherapists.com .

Still have questions? Let’s talk.

You deserve quality care. If you'd like to talk in detail about your specific needs please feel free to reach out and schedule a free 15-min Consultation call. I’d love to learn more about how I can support you.