How Does Couples Therapy Work With Insurance? A Clinician Explains What You Need to Know
Most couples assume their health insurance will help them pay for couples therapy. After all, therapy is therapy — right?
Unfortunately, it’s more complicated than that.
Insurance companies do not recognize relationship distress as a billable medical diagnosis. Because of this, most insurance plans do not cover couples therapy. What they cover is individual therapy for one identified patient, even if their partner is in the room. That distinction is not small — it changes the purpose, structure, and ethics of the entire therapy process.
Understanding these differences can help you make informed decisions, avoid frustration, and choose the type of support that actually meets the needs of your relationship.
Why Couples Therapy Usually Isn’t Covered by Insurance
Couples therapy treats the relationship, not one person’s mental health condition. The assumption is that something in the dynamic between the two of you needs to shift, and both partners participate as equal clients.
Insurance models don’t work this way.
To bill insurance, a therapist must:
identify one partner as the patient
give that partner a mental health diagnosis
provide treatment that focuses on that person’s symptoms, even if the other partner is present
Your relationship — the part you want help with — is not the thing insurance is paying the therapist to treat.
This creates an immediate and unavoidable mismatch between what couples therapy is and what insurance requires it to be.
Why Many Therapists Don’t Take Insurance for Couples Therapy
Therapists avoid insurance for couples work for several reasons:
1. Couples therapy isn’t medically necessary in the way insurance requires
Insurance wants to treat a disorder.
Couples therapy treats a relationship.
Those are not the same thing, and forcing one partner to be labeled with a diagnosis for the sake of payment can be clinically inappropriate and ethically questionable.
2. Insurance pays less for couples therapy than individual therapy
Despite its intensity, complexity, and the additional training required, reimbursement for couples therapy is lower than for individual therapy.
This creates a financial strain on clinicians and impacts access to high-quality care.
3. Insurance companies often delay, deny, or underpay claims
Couples therapists end up spending hours each week tracking down missing reimbursements. This is unpaid labor that takes away from time spent helping clients.
4. Insurance forces the therapist to treat one person instead of the relationship
This limits the therapist’s ability to:
treat the relationship as the client
use couples-specific modalities
work neutrally
hold both partners with equal care
It biases treatment from the very first session.
The Misconception: “My insurance says they cover couples therapy.”
This is where most couples get confused.
Insurance representatives often say “Yes, we cover couples therapy,” but what they mean is:
“We cover individual therapy (90837 or 90834) where your partner is allowed to attend.”
This is not couples therapy.
It is individual therapy with a partner present, which:
changes the treatment goals
changes the role of the therapist
creates ethical limitations
prevents the therapist from treating both of you as clients
Couples often don’t realize this until they’re already months into treatment and things still aren’t changing — because the therapy wasn’t designed to treat the relationship in the first place.
Serious Privacy Issues Most Couples Don’t Know About
In insurance-based therapy:
Only one person is the client
Only that person has legal access to the records
The partner does not have rights to the chart
In legal proceedings, only the identified patient's records can be subpoenaed
This becomes extremely problematic for couples therapy, where both partners are deeply involved in the work but only one is technically considered a client.
If a dispute, custody issue, or court case arises, the non-identified partner has no right to the therapeutic record — even though they participated in the sessions. This surprises nearly every couple.
Ethical Issues When Therapists “Try to Make It Work” for Insurance
Some therapists try to help couples use insurance by coding for individual therapy even when they are doing couples work.
This is a problem.
It misrepresents the service provided
It shifts the clinical focus away from the relationship
It forces the therapist to center one partner as the “patient”
It can become insurance fraud if done knowingly
It risks the clinician’s livelihood and license
This isn’t a harmless workaround — it has real consequences.
What About HSA/FSA and Superbills?
Couples can still use pre-tax healthcare funds, even if their insurance doesn’t cover couples therapy.
HSA/FSA
You can typically use HSA or FSA dollars to pay for therapy, including couples therapy, because these funds are tied to healthcare expenses, not insurance coverage.
Superbills
I do provide superbills for treatment, but with important limitations:
A superbill only works if the primary insured partner has out-of-network benefits
Insurance still will not reimburse for couples therapy unless they cover relationship diagnoses (most do not)
The identified patient still receives a diagnosis (relationship distress)
It is still considered individual treatment with a partner present
Superbills help some couples, but they don’t change the underlying insurance restrictions.
Comparing the Three Paths: Insurance, Private Pay, and Intensives
1. Insurance-Based Therapy (Individual Therapy With Partner Present)
Purpose: Treat the diagnosis of one partner
Pros:
Lower out-of-pocket cost
More accessible for individuals with severe symptoms
Cons:
Not true couples therapy
One partner is the “patient”
Treatment is diagnosis-driven
Limited privacy and legal complications
Restricted session length (45–53 minutes)
Therapist cannot fully treat the relationship
Best suited for: individuals needing mental health treatment, not couples seeking relational change.
2. Private-Pay Couples Therapy
Purpose: Treat the relationship
Pros:
Both partners are full clients
No diagnosis required
Greater privacy
Longer sessions (75–120 minutes)
Full use of couples therapy modalities (PACT, EFT, IBCT, Gottman, etc.)
Clinician can work neutrally and effectively
Faster, more meaningful progress
Cons:
Higher cost out-of-pocket
Limited third-party reimbursement
Best suited for: couples wanting to repair, rebuild, or deepen their relationship with a trained specialist.
3. Couples Therapy Intensives (Private Pay)
Purpose: Create rapid change, breakthroughs, and momentum
Pros:
Condenses months of weekly therapy into a few days
Removes daily stressors and distractions
Allows emotional breakthroughs
Gives couples traction that weekly therapy often can’t achieve
Creates a foundation for long-term healing
Cons:
Higher upfront cost
Requires time away from work and life
Not appropriate for all situations (i.e., ongoing safety concerns)
Best suited for:
couples in crisis
couples stuck in patterns that weekly therapy hasn’t shifted
couples needing immediate change
couples who want deep, immersive work
So How Does Couples Therapy Work With Insurance?
In most cases:
It doesn’t.
Not because therapists don’t want to help you, but because the insurance system is not designed to treat relationships — only individuals.
Couples therapy is specialized, intensive work that requires freedom, neutrality, and confidentiality. Insurance models undermine all three.
If you want to genuinely repair your relationship:
Private-pay couples therapy gives you access to a therapist trained to treat relationships
Couples intensives give you the breakthroughs and momentum that weekly therapy often cannot create
Insurance-based therapy may help one partner with their own symptoms, but it is not designed to heal the relationship itself
If You’re Ready to Strengthen or Save Your Relationship
If you’re considering couples therapy or exploring a couples intensive, I offer:
You don’t have to navigate this alone.
If your relationship feels stuck, strained, or on the brink, the right kind of therapy — the appropriate form of therapy — can make all the difference.
If you’re tired of repeating the same patterns, it’s time to get skilled help.
I work with couples who need a structured, intensive approach rooted in PACT and ISTDP. Book an intake appointment and we’ll identify the core issues quickly and map out the most effective path forward.
