Marriage counseling is a specialized form of psychotherapy designed to help partners navigate relationship conflicts and improve their communication and connection. Standard health insurance policies typically do not cover sessions focused purely on relational issues. Health insurance is designed to cover the treatment of illness and injury, meaning coverage for couples therapy is highly dependent on the medical rationale for the visit, not the desire for relationship improvement. Understanding the specific rules that govern mental health coverage is key to determining if and how your policy might apply to marriage counseling.
The Core Coverage Barrier
Health insurance operates under a medical model, structured to cover services deemed “medically necessary” for treating a diagnosable condition. Relational discord, communication breakdowns, or general unhappiness in a marriage are not classified as medical or mental health disorders in standard diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Because they do not represent a treatable illness, these issues fall outside the defined scope of most insurance coverage.
The distinction between individual and couples therapy is reflected in the billing codes used by providers. Individual psychotherapy is billed using Current Procedural Terminology (CPT) codes for a diagnosed condition in a single patient. Couples therapy is typically billed using a different CPT code, such as 90847 (“family psychotherapy with patient present”). Many insurance plans explicitly exclude this family-oriented code, or they only cover it when a specific medical necessity is established.
Insurers frequently decline coverage even when a therapist documents a relationship problem using a relational code, such as Z63.0 from the International Classification of Diseases (ICD-10). These “Z-codes” are considered factors influencing health status rather than a medical diagnosis requiring treatment, reinforcing the insurer’s position that pure relationship counseling is not a covered benefit. This focus on treating an individual’s illness is the primary reason why most claims for marriage counseling are denied.
When Coverage Is Possible Under Medical Necessity
Coverage for couples therapy is possible only when a clear “medical necessity” is established for one of the partners. This is managed through the “Identified Patient” model, where one spouse must have a diagnosable mental health condition, such as Major Depressive Disorder, Generalized Anxiety Disorder, or Post-Traumatic Stress Disorder. The therapy is then covered only if the therapist can document that the partner’s participation is a necessary component of the overall treatment plan for the diagnosed individual.
In this scenario, all claims for the joint sessions must be submitted under the name and insurance information of the diagnosed patient. The therapist must clearly justify how the partner’s presence directly contributes to mitigating the symptoms of the diagnosed condition. For example, a spouse may be included in sessions to help them understand how to support the diagnosed partner’s anxiety management or to reduce relational stress that exacerbates the individual’s depression.
It is important for both partners to understand that this process places a formal mental health diagnosis on the permanent medical record of the identified patient. This official diagnosis can have future implications, particularly when applying for life or disability insurance. Furthermore, the focus of the session must remain on treating the diagnosed condition, which can sometimes shift the therapeutic focus away from purely relational issues.
Exploring Non-Insurance Payment Options
For couples whose needs do not meet the strict “medical necessity” criteria, several practical alternatives exist to make counseling more accessible.
Employee Assistance Programs (EAPs)
Employee Assistance Programs (EAPs) are benefits often provided by employers to their workers and immediate family members. EAPs typically offer a limited number of sessions (three to eight per issue per year) at no cost and without requiring a mental health diagnosis. These sessions are excellent for initial assessment, crisis intervention, or focusing on specific communication skills.
Financial Planning Accounts
Financial planning accounts can be utilized to cover the cost of counseling. Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) allow individuals to use pre-tax money for qualified medical expenses. Although marriage counseling is not considered an eligible expense by the Internal Revenue Service (IRS), these accounts can pay for the out-of-pocket costs of individual therapy sessions if one partner is being treated for a diagnosed condition.
Reduced-Cost Services
Another option is seeking out licensed therapists who offer a sliding scale fee structure. Many mental health professionals are willing to adjust their session rates based on a client’s household income to improve access to care. Community mental health centers and university training clinics often provide services at significantly reduced rates, as they may utilize supervised student therapists or operate with government grants.