top of page

The Difference Between Eligibility and Benefits

Man questioning the difference between eligibility and benefits

As a mental health therapist, navigating the world of insurance can sometimes feel overwhelming. With complex terms and processes, it's important to have a clear understanding of the basics to ensure you can provide the best care for your clients. Two key concepts that often come up in the world of insurance are "eligibility" and "benefits." While they may seem similar and are often used as a single term, they have distinct differences that are important to understand. In this article, we'll explore the difference between eligibility and benefits, verification of benefits, plan year, deductible, and insurance, and how they impact your practice.

Eligibility refers to whether a client is covered by an insurance plan. It determines if a client has a valid insurance policy that can be used to pay for mental health services. Eligibility is usually determined by factors such as employment status, age, relationship to the policyholder, and enrollment in a specific insurance plan. It's essential to verify a client's eligibility before providing any services to ensure that they are covered and that you will be reimbursed for your services.

On the other hand, benefits refer to the specific services that are covered under an insurance plan. This includes the amount and type of services that are reimbursable by the insurance company. Benefits can vary greatly depending on the insurance plan and may include services such as therapy sessions, medication management, and psychiatric evaluations. Benefits may also have limitations, such as a maximum number of sessions allowed per year or restrictions on certain types of therapy. It's crucial to understand the specific benefits of each client's insurance plan to provide accurate information about their coverage and potential out-of-pocket costs. We’ve put together a diagram that you can use to help your clients understand how insurance works and what they are responsible for.

Verification of benefits is the process of confirming the details of a client's insurance coverage. This typically involves contacting the insurance company directly or using an online portal to check the client's eligibility and benefits. Verification of benefits is an essential step to ensure that you have accurate information about the client's coverage, including their copayments, deductibles, and any other out-of-pocket expenses. It helps you and your clients understand the financial aspects of their mental health care and make informed decisions about their treatment.

Understanding the plan year is also crucial when dealing with insurance. An insurance plan year is the specific time period during which an insurance plan's benefits are calculated. It typically lasts for 12 months, although it may not align with the calendar year. At the beginning of each plan year, the insurance plan resets, and deductibles, copayments, and out-of-pocket maximums may start over. It's important to be aware of the timing of the plan year, as it can impact the client's out-of-pocket expenses and coverage limitations.

When verifying benefits one of the pieces of information that you will want to acquire is what the patient will owe for your services starting with deductibles. Deductibles are the amount that a client must pay out of pocket before their insurance plan starts covering the costs. For example, if a client has a $500 deductible, they must pay $500 for eligible services before their insurance plan starts reimbursing for those services. Deductibles can vary widely depending on the insurance plan and can reset at the beginning of each plan year. It's important to inform your clients about their deductible and how it may impact their financial responsibility for mental health services.

Lastly, insurance plays a crucial role in determining eligibility and benefits. Insurance is a contract between the policyholder and the insurance company that outlines the terms and conditions of coverage. It's important to understand the details of the insurance plan, including the network of providers, copayments, deductibles, and coverage limitations. Being knowledgeable about insurance will help you provide accurate information to your clients and ensure that you are reimbursed for your services.

Practice Solutions specializes in serving the mental health industry, offering a valuable billing service to private practices including verification of eligibility and benefits. This essential service allows providers and practice owners to save countless hours throughout the year, freeing them up to focus on providing quality patient care. With Practice Solutions handling the time-consuming task of verifying eligibility and benefits as well as insurance billing, mental health practitioners can have peace of mind knowing that their billing and insurance processes are handled efficiently and accurately, allowing them to devote their attention to what matters most - their patients.

Related Posts

See All


Recent Posts
Search By Tags
Follow Us
  • Facebook Basic Square
  • Twitter Basic Square
  • LinkedIn
bottom of page