As you may be aware, many health plans reimburse at a lower rate for couples and family therapy than for individual therapy. I know, it doesn’t make sense. Shouldn’t they pay more when there are more clients in the session? I outlined some of the reasons for this strange reality in my article here.

But what can be done?

As a first step to advocate toward equal or greater reimbursement for couples and family therapy, in June of 2025 I compiled a therapist survey exploring this issue.

My hope was to use the survey results to convince the American Medical Association to replace the current single CPT code for family and couples sessions with patient present, defined as a 50-minute code, billable for sessions of 26 minutes or more. I wanted to advocate for 3 new CPT codes for 30-, 45-, and 60-minute couples and family sessions, in the hopes that health plans would then at least match the rates for individual sessions of the same lengths. I also wanted to advocate to replace the current 90846 code with 3 codes, for use with family and couples sessions without the patient present.

However, I soon learned how challenging it can be to get new codes approved. In fact, I heard from many authoritative voices within our field about how past efforts to petition the AMA for new codes for extended couples and family therapy sessions had failed. I also learned that the AMA has VERY high standards and criteria for the consideration of any new code. They do not allow the splitting of current codes, and require peer-reviewed research, evidence, and testimony documenting the need for any new code.  I was told that they don’t really allow looking into changing of some psychotherapy codes without opening up ALL the psychotherapy codes for review. Finally, I was told that any changes in the CPT codes at this point could actually hurt some therapist due to certain Medicare contracts.

Also, the AMA only meets a few times a year to review new code applications, which must be submitted months in advance of their meetings, and they will want written support from professional associations.  While I was able to speak to representatives of five major professional associations, they did not advise making changes at this time, and promised that they were working on major changes to the psychotherapy codes.

I am supremely disappointed, but I feel like I have hit a brick wall.  I now realize it will require more time, effort, and research than I could have imagined to continue this fight, just at a time when I am “mostly-retired,” so I’m not sure I have it in me.

But I can’t thank you all enough for the 4305 comments (!!!) that I received from those of you who took the survey.

In the meantime, I wanted to thank all of you who participated in my survey, and to give you a summary of your answers.

SURVEY RESULTS

Who took the survey: 3266 therapists from every state in the USA, Washington DC, and Puerto Rico took the survey between June 1 and July 31 of 2025. The survey was announced to my nationwide mailing list via newsletter and to various online therapist listservs, and respondents were asked to share the survey link with colleagues and their professional associations. Therapists were invited to take the survey even if they did not participate with health plans and/or did not work with couples or families.

A summary of answers to individual questions are given below, and a summary of the survey is at the end of this article.

QUESTION SUMMARIES

1. Which best describes you?

2. What percentage of your practice is couples / family work?

3. Have you experienced an insurance plan reimbursing your services at a lower rate for a couples or family therapy session (CPT code 90847 or 90846) than is paid for individual therapy sessions (CPT code 90834 or 90837)? (CHECK ALL THAT APPLY)*

4. If you have experienced a rate reduction, what is the MAXIMUM reduction that have you have experienced for a couples/family session (CPT 90847) as compared to an individual 60-minute session (CPT code 90837)?

5. Has this lower reimbursement rate for couples and family therapy ever been a factor that kept you from JOINING an insurance plan?

6. Has this lower reimbursement rate for couples and family therapy ever been a contributing factor that led you to RESIGN (or consider resigning) from an insurance plan?

7. Network therapists: Has a lower reimbursement rate for couples and family therapy caused you to turn away potential new couples and families, or to tell them you could not see them using their insurance?

8. Do you have reason to believe the lower reimbursement rate for couples and families is affecting therapy access? (CHECK ALL THAT APPLY)*

9. Typically, insurance plans don’t cover longer couples and family sessions (ex. 90 minutes or more). Which best describes the effect this has on your treatment? (CHECK ALL THAT APPLY)*

HIGHLIGHTS / SUMMARY

88% of survey respondents were network providers for health plans, a majority reporting they were contracted with multiple plans. 86% of respondents said they worked with couples or families. It should be noted, however, that these figures may be higher than the nationwide percentage of therapists who are contracted with insurance and who work with these clients, as one might speculate that couples and family therapists who accept insurance would be more motivated to take the survey, and thus may be overrepresented.

Of the 2805 clinicians who worked with couples and families, 61% estimated that less than half of their practice were families and couples, while 39% estimated that at least half of their clients were families and couples. It is very possible that these numbers would change if insurance reimbursement was higher for these populations.

This survey highlights just how prevalent and significant the issue of lower reimbursement for couples and family therapy is for the majority of respondents. Only 9% said they had never experienced a lower rate for couples or family therapy from a health plan. An overwhelming 82% of network providers had experienced this issue, as had 18% of out-of-network providers.

And the reported rate reduction was surprisingly substantial. Almost 80% of respondents reported they had received more than $15 less for a couples or family session than what they would have been paid for an individual session. Considering that insurance rates for individual sessions are already reduced – often half of a therapist’s regular fee, an additional reduction of more than $15 per session for all couples and family sessions may represent an unsustainable income loss, and can lead therapists to avoid providing these types of sessions.

This reimbursement reduction also clearly has led therapists to take extreme steps to protect their income. Over one-third (37%) reported they had avoided joining health plans because of this issue. Over half said they had resigned or considered resigning from a health plan due to the lower rate. Over one-third (36%) said they were tempted to turn away couples and families due to the lower reimbursement. But perhaps most notably, a full 40% said they HAD turned away couples or families due to the lower rate, or refused to take their insurance. It is important to note here that refusing to accept a client’s insurance would be a violation of  the therapist’s health plan contract, since network therapists are not permitted to accept clients who are plan members while declining to accept their insurance.

Almost all respondents (97%) stated they were aware that this lower reimbursement for couples and families was affecting therapy access. 70% said they knew of therapists turning away couples and families due to the lower rate, and 63% reported they knew therapists were leaving health plans or not joining because of this issue, giving clients fewer care options. 75% stated their clients had reported difficulty finding in-network couples and family therapists that would see them or that would accept their insurance, so that these clients wound up paying out of pocket, or were unable to afford treatment. And 75% expressed concern about the negative impact on low-income, minority, and marginalized families and communities.

Since health plans usually don’t reimburse for longer sessions (defined here as 90 minutes or more), more than half of survey respondents (55%) said they avoided providing the longer sessions that they felt their couples and families needed, and this meant they were not always able to use the most effective techniques, or to reach goals as quickly. This could also mean that the treatment might take more sessions, and be less effective at reducing symptoms, thus represent higher cost to the client or health plan. Almost half (46%) reported they provided longer sessions while knowing they would only be paid the same as a 50-minute session, and another 18% said they didn’t bill insurance for longer sessions – meaning 64%  of respondents were experiencing unpaid treatment time and income loss. 15% reported the fee for the extra time was being paid by clients, who could not get reimbursed for this care, an option that many lower-income clients would be unlikely to be able to afford.

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When can couples therapy be billed to insurance – and when can’t it?  Find out the answer to this question and all your questions about working with couples in my online course “Couples Therapy: Billing, Documentation, and Ethical Dilemmas.” It is sure to challenge your thinking about working with couples. Check out this course here.