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Sliding Scale Therapy: What It Is and How to Get It

Sliding Scale Therapy: What It Is and How to Get It

You thought you were doing the right thing—seeking therapy to work on psychological healing or personal growth and making sure you used your hard-earned insurance to cover it. But then you ran into a problem. Even after you worked your way through the list of therapists your family and friends recommended and started searching online, you kept finding therapist after therapist who didn't accept your insurance. Maybe you finally found one, but they didn't have the right specialty, or maybe you found no therapists in your area who accepted your insurance at all.


If you've struggled to find a therapist who accepts your insurance, you're not alone. Many mental health professionals only participate in one or two insurance networks, and fewer and fewer therapists participate in any insurance networks at all. The reasons therapists give for giving up on insurance are numerous:


  • The amount of paperwork they have to do for insurance companies results in hours of unpaid labor every week;
  • Even after doing all that work, insurance companies fight with them over paying claims, quibbling with everything from diagnoses to whether therapy is "medically necessary";
  • The amount that insurance is willing to pay is significantly less than what many people are willing to pay out of pocket for therapy; and
  • Many insurance companies are refusing to accept any new therapists into their networks.


Another issue you may have run into is downloading a list of in-network mental health providers from your insurance company, only to find that almost none of the names or numbers on the list lead to in-network providers. In fact, these "ghost networks" are so common that some people believe insurers create them intentionally to keep people from finding in-network therapists. Even if these inaccurate lists are simply a mistake, they're a symptom of a larger issue: finding an in-network therapist has become an impossible task for many people.


When Insurance Isn't an Option

Of course, in-network therapists are only an option if you actually have insurance, and if you don't, you're in good company. With an increasing number of people working as freelancers in the gig economy, and with individual plans on the exchange becoming more restrictive every year, many people have limited or no insurance coverage.


The good news is that there are options for people who can't afford to pay $150 or $200 an hour for therapy. Ways to get help with the cost of therapy include seeking financial assistance through the public mental health system, getting therapy at low-cost local non-profit clinics, or seeing private practice therapists who offer affordable sliding-scale fees. In this article, we'll cover how sliding-scale therapy works and how to use it to get high-quality, affordable therapy in your area.


What Is Sliding-Scale Therapy?

Sliding-scale therapy is simply therapy offered for sliding-scale fees based on a person's income. Both non-profit clinics and private practice therapists frequently use this method to make therapy accessible for people who can't afford their standard rates.


The reason private practice therapists offer sliding-scale fees is so they can succeed financially while still being able to help people who can't afford their regular rates. Therapy rates can seem high, but they reflect the costs therapists have to absorb to maintain their practices. In addition to paying individual taxes and renting office space, private practice therapists have to pay for their own health insurance, liability insurance, licensing fees, and continuing education courses and credits they must take to maintain their licenses.


Most therapists don't believe that a person's income should determine whether or not they get therapy. While therapists are people, and some are greedy or otherwise unethical, far more are compassionate people who want to help as many people as they can. Most therapists wish they didn't have to turn anyone away but know that they couldn't survive as professionals and support their families if they didn't charge competitive rates, or "reasonable and customary" rates for where they live. When therapists can't consistently offer therapy for rates everyone can afford, sliding-scale fees are one way they can compromise and open their doors to more people.


How Does Sliding-Scale Therapy Work? 

A sliding fee scale is a range of rates assigned to people based on a specific variable, usually their income. The way therapists set up sliding scales varies. Some assign a specific fee to a set range of incomes. For example, a therapist might charge people who make $30,000 to $40,000 a year $40 per session, while charging people who make $120,000 to $150,000 a year $150 per session. Some use a formula to determine their fees, such as [0.001] x [Annual Income].


Most therapists who offer sliding-scale fees mention it on their website or profile page. Many won't list their full fee scale online, especially on sites they don't update frequently, as rates may change over time. To find out what fee you'd be assigned to pay per session, you can call or e-mail the therapist to inquire. Some may ask for proof of income, but some won't.


Since most sliding-scale fees are tied to income, your rate may change if your income changes significantly. If you lose your job and have to take an interim job that pays less, your therapist may be willing to lower your fees, especially if you both already have a good working relationship.


Public or private non-profit mental health clinics often offer sliding-scale therapy for lower rates than private practice therapists. One reason is that these clinics frequently receive income from sources private practice therapists don't have, like state or federal grants or charitable donations.


How to Ask About Sliding Scale Therapy 

Even if a therapist doesn't specifically advertise that they offer sliding-scale fees, it doesn't hurt to ask. A good therapist won't be upset by a polite, reasonable request for a reduced fee from a client who wants to see them but who can't afford their full rate. Do consider whether you can actually pay, though. It's fair to ask for help so you don't have to skip car maintenance or a trip to the grocery store to see a therapist, but trying to hide your income so you can still buy that giant gold-plated foot statue for your garden isn't really fair to the therapist or their other clients.


Some therapists don't offer a sliding scale because they accept insurance and don't want their rates cut by insurance companies. Some fear upsetting or losing clients who would find such a system unfair. Therapists who decide against offering sliding scales sometimes choose another way to help clients who can't afford their regular rates. Other cost-reduction methods therapists use include providing a certain number of pro bono sessions a week, allowing clients to sign up for payment plans, or offering half-hour sessions for half of their hourly rate. If a therapist tells you they don't offer a sliding scale, ask if they offer any other options like these.


If you're not finding private practice therapists who offer sliding-scale fees you can afford, think outside of the box. In addition to low-cost public or private non-profit mental health clinics, consider looking into integrated health clinics where you can get physical and mental health care for lower rates than you'd pay to see a doctor and a therapist separately. You can do an internet search for terms like "integrated care clinics" or "integrated healthcare" for your area or search for a federally qualified health center (FQHC) using the online search tool on the U.S. Department of Health and Human Services website. Most FQHCs and integrated healthcare clinics accept a wide range of insurance plans in addition to offering sliding-scale fees.


You can also use the search tools on OpenCounseling to look for therapists in your area who offer therapy for reduced fees. Helping people find affordable therapists is why the site was created! Also consider trying affordable online therapy through BetterHelp (a sponsor). Because online therapists don't have to cover a lot of the same costs as therapists who see clients in a brick-and-mortar office, online therapy is often more affordable. In any case, keep searching—you may be close to finding an option that works for you.

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Stephanie Hairston, MSW
Posted on 12/01/2019 by Stephanie Hairston, MSW

Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a masters-level clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments. She has also worked as a technical writer for a medical software company and as an editor for a company that appeals denials of insurance coverage for behavioral health treatment. As a writer, she is motivated by the same desire to help others that brought her into the field of social work and believes that knowledge is one of the most essential recovery tools. She strongly believes in the mission of OpenCounseling and in making therapy accessible for everyone.