Outpatient therapy & psychiatry

Individual, couples, and family therapy with licensed clinicians (e.g., LCSW, LMFT, LPC, psychologist).

Psychiatric consultations and ongoing medication management.

Evidence‑based treatments (e.g., CBT, DBT) when medically necessary.

Capped at 40 visits per year for each covered individual.

Virtual/telehealth visits

Video or phone therapy/psychiatry with in‑network providers is covered the same as in‑person unless noted in your Plan Summary.

Great for convenience, continuity, and access to specialty care.

Intensive/structured programs (with prior authorization)

Intensive Outpatient Programs (IOP), Partial Hospitalization Programs (PHP), and other structured day programs.

Prior authorization is typically required for these services and for most inpatient behavioral health admissions.

Inpatient & crisis stabilization (with prior authorization)

Hospitalization or residential treatment for acute mental health or substance use needs.

Emergency services are always covered according to your plan, but ongoing stays generally require authorization.

In‑Network

You’ll pay the lowest out‑of‑pocket amounts when you see in‑network mental health providers.

The provider has agreed to Solo’s contracted rate and will not balance bill you beyond your normal cost share.

Teletherapy with an in‑network clinician is typically covered at the same level as in‑person care.

Out‑of‑Network (OON)

You can use out‑of‑network providers, but you will usually pay more.

Your plan pays the allowed amount (Solo’s maximum payable for a given service); you pay:

a) your plan’s OON cost share plus

b) any balance bill if the provider charges above the allowed amount.

OON claims often require you (or your provider) to submit a detailed bill (superbill) and proof of payment if the provider doesn’t bill the plan directly.

Prior authorization rules still apply—especially for IOP, PHP, residential, and inpatient stays—whether in or out‑of‑network.
Balance Billing: Out‑of‑network providers can bill you the difference between their charge and the plan’s allowed amount. This can be significant for therapy and psychiatry visits over time.

You’ll almost always save money—and avoid balance bills—by choosing in‑network therapists and psychiatrists. It also reduces paperwork because in‑network providers bill the plan for you.

• Medications prescribed by an in‑network psychiatrist or primary care provider are covered under your plan’s prescription benefit and formulary (list of covered drugs).
• Some medications may require prior authorization, step therapy, or have quantity limits.
• For the best price, ask about generics or preferred brands, and make sure your pharmacy is in‑network.

• Stay in‑network whenever possible—particularly for recurring therapy/psychiatry visits.
• Verify benefits before starting higher‑level care (IOP/PHP/residential/inpatient).
• Use telehealth with in‑network providers for convenience and equal coverage.
• Ask for a treatment plan and billing codes (CPT codes) up front so you can estimate costs.
• If OON is your preferred option, ask the provider to:

  a) Bill your plan directly (if they will), and

  b) Consider a rate closer to the plan’s allowed amount to reduce balance billing.

• If your OON provider doesn’t file claims:

  1) Collect an itemized receipt/superbill with diagnosis and CPT codes, dates of service, and the provider’s NPI and tax ID.

  2) Submit the claim using the instructions on the Medical Claim Form.

  3) Keep copies of your bills and documentation.

• Member Services: Call the number on your ID card for coverage, network, or authorization questions.
• Care Management: If you’re entering IOP/PHP or an inpatient/residential program, ask to speak with care management to coordinate authorizations and smooth transitions of care.
• Appeals: If a claim is denied, you have the right to appeal. Use the instructions on your Explanation of Benefits (EOB) and submit any supporting clinical notes from your provider.

• Do I need a referral to see a therapist or psychiatrist?

  No, you do not need a referral.

• Are teletherapy sessions covered?

  Yes, typically at the same level as in‑person when using in‑network providers.

• Can I see an out‑of‑network therapist?

  Yes, but you may pay more and face balance billing.

• Do higher‑level programs need authorization?

  Yes—IOP, PHP, residential, and inpatient behavioral health typically require prior authorization.