Using Insurance for Couples Therapy in California: What You Need to Know

Most insurance plans cover individual therapy for mental health care, but the guidelines are less clear when it comes to couples therapy. There’s good news for couples in Riverside because Inland Empire Couples Counseling is now in-network with IEHP (Inland Empire Health Plan). This means that more couples in our community can get the support they need without worrying about the costs of therapy coming out of their pockets. 

If you’ve never used health insurance for couples therapy before, the process can be a bit confusing. Insurance rules around relationship counseling work differently than you might expect, and we want you to walk into your couples or marriage counseling fully informed. Let’s take a look at the breakdown of insurance for couples therapy, and how it all works. Have more questions? Visit our FAQs page.

First, a Quick Intro to IEHP

IEHP is a health plan serving residents of Riverside and San Bernardino counties. Depending on your situation, you may be enrolled through one of three different IEHP programs, including IEHP Medi-Cal (no-cost or low-cost coverage for qualifying low-income residents), IEHP DualChoice (which combines Medicare and Medi-Cal benefits), or IEHP Covered (plans available through Covered California). All of these plans include coverage for behavioral and mental health services.

Because your specific plan type affects things like copays, deductibles, and coinsurance, the exact costs you'll pay can vary from person to person.

Receiving Insurance Coverage When Couples Therapy Doesn’t Exist as a Billing Category

With all insurance companies, and not just IEHP, there is no insurance billing code for "couples therapy" as its own category. That's because health insurance, including Medi-Cal-based plans like IEHP, is built to cover medical issues, which include mental health care. 

Relationship struggles, on their own, aren't classified as a medical condition, so insurers aren't required to pay for them the way they are for something like depression or anxiety. 

There’s also the issue that during couples therapy there are two people technically receiving treatment, and insurance providers are only willing to provide coverage for the individual enrolled in their plan. 

That doesn't mean couples therapy isn't covered. It does it has to be billed in a specific way in order to qualify for payment or reimbursement.

How Can Your Health Insurance Cover Couples Therapy?

For your sessions to be covered, the partner who is using the insurance needs to have been diagnosed with a covered mental health condition. For example: 

• Anxiety

• Depression

• PTSD

• ADHD

• Adjustment disorder (difficulty coping with a specific life change or stressor)

Once that diagnosis is in place, it becomes possible to prescribe couples therapy as a means of improving the individual’s mental health condition. That partner is then labeled as the “identified patient”, whose diagnosis is being treated with family therapy. The family or couples therapy then becomes the treatment method that is used to help manage and improve the symptoms of the initial diagnosis. 

While having one identified patient is essential for insurance coverage, this in no way means that only one partner is benefiting from the therapy sessions. It’s basically a technicality that allows couples therapists to provide their clients with services they need, while minimizing the out-of-pocket costs they’re responsible for. 

That said, we want to be really clear about something. This is a billing requirement, but it does not mean that we believe the relationship problems are your partner’s fault or that one person is to blame for what’s going on between you. It also is not meant to minimize the depression, anxiety, and other mental health symptoms the non-identified partner may be experiencing due to issues within the relationship. 

This is simply how insurance companies in California are structured to process claims. We’re using couples therapy as a tool to help treat that individual’s diagnosis while, in reality, working with both of you as a couple.

What Getting Insurance to Cover Couples Therapy Looks Like for You and Your Partner

So, to recap, if you have insurance and want to use it to cover the approved amount of your therapy sessions, the process will look something like this:

One partner with insurance, including IEHP, will need an evaluation and a qualifying diagnosis.

It will need to be determined by your therapist that couples counseling will be beneficial in improving the outcome of the diagnosis.

Couples therapy sessions will be billed as a type of treatment for the specified diagnosis.

Your therapist will check in regularly to assess how treatment is progressing and if there has been an improvement since the diagnosis. For example, the therapist may ask the individual who is covered by the insurance if they have noticed any improvements in their anxiety, depression, etc., since starting the therapy.

You may be tempted to answer no to these questions, thinking that insurance companies will see that as reason to continue therapy until improvement happens, but the opposite is actually true. Insurance companies want to see proof that the treatment is working, and will usually only continue coverage if there has been improvement since the diagnosis.

What About Co-pays and Deductibles?

IEHP offers a few different plan types, as do many other insurance carriers. Your actual out-of-pocket costs will depend on the type of plan you are enrolled in. Some examples of out of pocket expenses include:

• Copay: A flat fee you pay at the time of your appointment.

• Coinsurance: A percentage of the session cost you're responsible for, rather than a flat fee.

• Deductible: An amount you may need to pay out of pocket before your insurance coverage kicks in for certain services.

Because these amounts differ depending on your specific IEHP or health insurance plan, the best way to know exactly what you'll owe is to check the front and back of your member ID card or call Imember services directly.

What Happens If Insurance Denies the Claim?

Every insurance provider, including IEHP, determines eligibility and coverage on a case-by-case basis, and claims aren't guaranteed to be approved. It's smart to be prepared for the possibility that you may need to cover some cost out of pocket if a claim isn't approved as expected. We'll always do our best to communicate clearly with you if this comes up.

Frequently Asked Questions

Does IEHP cover couples therapy?

IEHP covers mental health and behavioral health services, and couples therapy can be covered when it's used to treat a qualifying mental health diagnosis (like anxiety, depression, or PTSD) in one partner, billed as family therapy.

Why does one partner need a diagnosis for couples therapy to be covered in Riverside, CA?

Insurance companies, in general, only cover services tied to a medical diagnosis. Since relationship issues alone aren't classified as a medical condition, one partner's diagnosis becomes the basis for coverage, even though the actual therapeutic work addresses the relationship as a whole.

What if I don’t want a mental health diagnosis on my medical record?

Although there is less stigma surrounding mental health care, and workplace protections in place against discrimination, this is still a valid concern.  If you'd prefer not to have a diagnosis documented, private pay (without billing insurance) is an option worth discussing with your therapist

Can my claim be denied, even if I have an approved diagnosis?

Yes. Insurance companies, including IEHP, evaluate claims individually, and coverage isn't guaranteed in every case. It's a good idea to be financially prepared for the possibility of an out-of-pocket cost.

Questions About Starting Couples Therapy in Riverside, CA?

Have questions about starting couples therapy with your IEHP coverage or another type of insurance? Reach out to Inland Empire Couples Counseling — we're happy to walk you through what this looks like for your specific situation. We offer individual and couples counseling services in Riverside, CA, as well as online. We invite you to contact us at Inland Empire Couples Counseling to learn more about our practice, our providers, and how we can help.

Rebecca Williams, LMFT, is a committed licensed Marriage and Family Therapist in Riverside, CA, with a Master’s degree from Loma Linda University. She helps individuals and couples heal emotional wounds, strengthen relationships, and build lasting, fulfilling connections.

Rebecca has advanced training in addiction treatment, family therapy with teens, and multiple evidence-based couples therapy approaches. She has also spoken on topics including faith transitions, the coming-out process, wellness, and leadership.