invited you to try Thrizer! Start your free trial and enjoy waived credit card fees for your first in charges.
Ketamine therapy is picking up a lot of steam in 2024.
There are between 500 and 750 ketamine clinics in the United States, with a projected $6.9B market cap by 2030.
Ketamine has even been endorsed by celebrities like Chrissy Teigen, Lamar Odom, and Elon Musk, making it feel less intimidating for others.
But for any of us non-celebrities, ketamine therapy can be out of reach financially.
At $300 per session on the low end, and close to $800 on the high end (usually as part of a package deal), ketamine therapy isn’t the most accessible mental health treatment.
So, you’re not alone if you’re asking, “Is ketamine therapy covered by insurance?”
I asked 3 experts for their insights on this fascinating, effective, and novel treatment, and how you can hopefully get it covered by your insurance.
First, let’s do a brief overview of ketamine as used in therapeutic settings.
The most common forms of ketamine in therapy are infusions, nasal spray (esketamine), and sublingual lozenges.
Ketamine infusions use an IV to administer your dose of ketamine. Of course, you’ll need to be at the clinic to receive your infusion.
Esketamine nasal spray is another form of ketamine commonly used in therapy and is marketed as Spravato.
After spraying into your nose, Esketamine gets absorbed into your bloodstream via your mucous membrane. This is the only FDA-approved use of a form of Ketamine as of the writing of this article, so coverage is more common.
Lastly, sublingual lozenges are safely dissolved under your tongue and absorbed into your bloodstream. Some clinics and services offer to mail you sublingual lozenges for home use with the assistance of online therapy.
When you go for a ketamine therapy session, a licensed medical doctor or nurse will administer the ketamine in a predefined route, based on you, your medical history, and other factors.
A licensed psychotherapist will be with you throughout your experience, or afterward depending upon the clinic. There is not yet a national standard on how best to support a client during ketamine therapy, so every clinic is slightly different.
Most clinics offer single sessions or packages of six to ten, the latter costing in the thousands.
Insurance coverage for ketamine therapy varies by state, insurance plan, prior authorization, and medical history.
Now that we’ve done a quick explainer of ketamine therapy, let’s look at insurance coverage and reimbursement.
When it comes to ketamine therapy, coverage is complex, reflecting the novel nature of the treatment. What might you expect if you're looking to have your sessions covered?
The consensus among experts about insurance coverage for ketamine infusions can seem contradictory at first glance. Dr. Brian W. Boyle, Chief of Psychiatry at Stella, told me coverage is possible.
“Ketamine-assisted psychotherapy is not generally covered by insurance plans, though it may be possible to get some coverage for the psychotherapy component of the treatment,” he said. It depends “on how a clinic chooses to code a visit.”
So one factor in coverage is how your clinic or therapist “codes” the visit for insurance. Coding is how a mental health provider communicates what services were rendered to the insurance company.
On the flip side, Mariya Javed-Payne, a somatic therapist in Minnesota, observes that Ketamine infusions are often covered under certain circumstances, especially when clinics utilize specific billing codes that insurance might recognize.
“During the actual medicine session in KAP, the medical provider’s portion may be covered using outpatient E/M codes and with an extender code,” she said.
That’s a significant help if you’re looking to get insurance to cover your ketamine-assisted psychotherapy sessions. The medical portion may be covered. What about the therapy portion?
Javed-Payne added, “One hour of psychotherapy, sometimes 2, can also be covered for the client for the medicine portion but this requires doing active psychotherapy.”
Ultimately, coverage varies on your state’s laws, insurance plan, and how your therapist and medical provider bill the insurance plan.
When we shift our focus to esketamine, marketed as Spravato, the insurance outlook brightens considerably.
Dr. Boyle told me, “Yes, intranasal esketamine, also known as Spravato, is covered by most insurance plans, as long as patients meet criteria for treatment-resistant major depressive disorder. Spravato is FDA-approved for this indication.”
That’s great news for anyone looking to get help for depression!
Javed-Payne adds a layer to this, noting that insurance only covers select patients who meet stringent criteria. These criteria include:
1) Diagnosis of treatment-resistant depression
2) Two or more previous anti-depressants that did not help
3) Currently taking a prescription antidepressant
She also noted that prior authorizations may be required.
Spravato/esketamine presents a more straightforward path for those battling persistent depression.
Remember, checking with your insurance provider for the specifics of your coverage can save you from unexpected bills and ensure that your journey toward healing is as smooth as possible.
Dr. Boyle told me, “Intranasal esketamine, or Spravato, is covered by all major insurance plans, as long as patients meet criteria for treatment-resistant major depressive disorder.”
And what about IV ketamine infusions?
“Intravenous ketamine infusions are ostensibly covered by Blue Cross Blue Shield and Mass General Brigham plans, though there are practical limitations on the availability of these services,” he said.
For further clarity, he added, “I am not as familiar with the coverage landscape outside of Massachusetts, though my sense is that it is similar in other states.”
Javed-Payne commented on her view from Minnesota, saying “BCBS, HealthPartners, and UCare are the only three that we know of currently. Other insurers are working to include ketamine treatments.”
Though these rates will vary by plan, seeing how some plans reimburse can be helpful. I asked Javed-Payne and Dr. Boyle for the reimbursement rates they’ve seen in their clinics.
Javed-Payne:
“These numbers represent better insurance plans with the highest coverage,” she clarified.
“In general, insurance will reimburse at the rates that are contracted for the specific medical and psychotherapy codes used as they would for those services in other settings. There is no specific billing for ketamine-assisted psychotherapy at this time,”Â
Dr. Boyle:
“Insurance reimbursement for intranasal esketamine, or Spravato, varies widely, depending on the type of visit coding dictated by a particular plan's policy. Reimbursement typically ranges from about $300 to $500 per visit,” he said.
In some cases, you may be required to pay the copay. And in all cases, it’s a good idea to seek prior authorization from your primary physician.
Dr. Ryan Sultan is a Columbia professor who has been running a ketamine clinic since 2011. I asked about his experience with ketamine therapy coverage.
“In general reimbursement isn’t great for ketamine for patients overall. It’s new. You sorta have to bill in a creative way to try to help your patients get it paid for,” he said.
Yet he added that if your ketamine therapy provider has an in-house medical provider, reimbursement rates will be much better.
“Sadly, our therapist-only friends are much lower in reimbursement. Particularly, since therapists (MHC, PhDs, LCSWs) don’t have a license to dispense a medication of any sort. So there is no way for them to bill for ketamine legally,” just the therapy aspect of KAP.
If you’re among the 3 million Americans who face treatment-resistant depression (TRD) every day, ketamine therapy can be a godsend.
In this article, we’ve covered some of the ins and outs of coverage with the help of 3 experts who work with ketamine in therapeutic settings. Here are some of the main takeaways:
If your insurance plan does not yet cover ketamine therapy, there’s still cause for hope. Organizations like the Ketamine Task Force and the ASKP3 are working hard to break down barriers to treatment.
In the meantime, Thrizer can help you use your out-of-network benefits to cover the cost of therapy. Try our superbill upload service which is only $2/submission.
___
This blog post is provided for informational purposes only and is not intended as legal, business, medical, or insurance advice. Laws relating to health insurance and coverage are complex, and their application can vary widely depending on individual circumstances and state laws. Similarly, decisions regarding mental health care should be made with the guidance of qualified health care providers. We strongly recommend consulting with a qualified attorney or legal advisor, insurance representative, and/or medical professional to discuss your specific situation and how the laws apply to you or your situation.
