Maybe you make too much to qualify for Medicaid, but the insurance available through work still feels expensive. Maybe you have insurance, but every therapist you’ve called is booked, out of network, or unfamiliar with what you’re looking for. Or maybe you’re on a parent’s or partner’s plan and want to know who could see that you went to therapy.
These are some of the reasons people consider private-pay counseling, also called self-pay. It means paying the therapist directly for your sessions. You might be uninsured, or you might have insurance and choose to pay directly for a particular service.
When insurance is hard to use
There’s a group of people I think about a lot in this work. They’re trying to get by on what they earn, they may be over the income limit for Medicaid, and the cost of getting care still stretches their budget. Some may qualify for savings through the Health Insurance Marketplace. An offer of job-based coverage can affect eligibility for those savings, and the Marketplace uses its own definition of what counts as affordable (HealthCare.gov, n.d.). A plan can meet that definition and still feel expensive when you sit down to pay your bills.
Even if you have insurance, what you pay for a session can depend on your deductible, copay, and whether the therapist is in network. A sliding-scale rate gives you a number to compare with what you’d pay using your plan. Sometimes insurance costs less. Sometimes the direct-pay rate fits your budget better. Either way, it helps to ask what a typical month of therapy would cost.
When you want more control over who sees your billing information
If you’re an adult on someone else’s health plan, it’s reasonable to wonder what the policyholder can see. An Explanation of Benefits, or EOB, can show the date of a visit and who provided the service (Centers for Medicare & Medicaid Services [CMS], n.d.-a). If you’re queer or trans and decide carefully who gets to know about your life, even a billing notice can feel like more information than you want someone else to have. You might want a place to talk through questions about identity, family, or relationships before deciding what you want to share outside therapy.
When you pay in full out of pocket, you can ask a provider covered by HIPAA to restrict what they share with your health plan about that visit. The provider must honor the request for disclosures related to payment or health care operations when the information pertains solely to the service you paid for and disclosure is not required by law (U.S. Department of Health and Human Services, 2022). Your therapist still keeps a clinical record, and the usual limits of confidentiality still apply. If you later submit a receipt or superbill for reimbursement, you’re sharing information about the visit with the insurer.
If you’d prefer to use your insurance, you can ask the plan what the policyholder can see and whether billing notices can go directly to you. Under HIPAA, health plans must accommodate reasonable requests for confidential communications when you clearly state that disclosure could endanger you (45 C.F.R. § 164.522(b), 2025).
When you find a therapist you feel comfortable with
Sometimes the therapist you’d like to work with is outside your insurance network. Maybe they have experience with late-diagnosed ADHD, or you can talk about your gender or relationship without spending half the session explaining the basics. If the fee is manageable, paying directly can give you a wider pool of therapists to choose from.
In a KFF report published in 2024, 33% of LGBT adults said a health care provider had treated them unfairly or disrespectfully in the previous three years, compared with 15% of non-LGBT adults (Montero et al., 2024). The survey asked about health care broadly. For someone who’s already had an experience like that, it makes sense to take time finding a therapist they feel comfortable with.
What to ask before you schedule
What would I pay per session, and what might that add up to in a typical month?
Do you offer a sliding scale, and how does it work?
If I pay directly, what information goes to my insurance plan? How will you send appointment reminders and receipts?
Can I get a written Good Faith Estimate? If you’re paying without using insurance, federal rules generally require providers to give you one when you request it or schedule at least three business days ahead (CMS, n.d.-b).
At Small Works Counseling, I offer sliding-scale rates because people can have similar incomes and very different amounts left over after rent, groceries, or caring for family. If you’re considering working with me, you’re welcome to ask about rates, billing, and privacy before you schedule. You deserve to know what therapy will cost and how your information will be handled before you decide.
References
Centers for Medicare & Medicaid Services. (n.d.-a). How to read an explanation of benefits (EOB). https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/guides-resources/read-explanation-benefits
Centers for Medicare & Medicaid Services. (n.d.-b). What is a good faith estimate? https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/guides-resources/what-good-faith-estimate
HealthCare.gov. (n.d.). Affordable coverage. Retrieved November 4, 2026, from https://www.healthcare.gov/glossary/affordable-coverage/
Montero, A., Hamel, L., Artiga, S., & Dawson, L. (2024, April 2). LGBT adults’ experiences with discrimination and health care disparities: Findings from the KFF Survey of Racism, Discrimination, and Health. KFF. https://www.kff.org/racial-equity-and-health-policy/lgbt-adults-experiences-with-discrimination-and-health-care-disparities-findings-from-the-kff-survey-of-racism-discrimination-and-health/
Rights to request privacy protection for protected health information, 45 C.F.R. § 164.522 (2025). https://www.govinfo.gov/content/pkg/CFR-2025-title45-vol2/pdf/CFR-2025-title45-vol2-part164-subpartE.pdf
U.S. Department of Health and Human Services. (2022, December 28). Under HIPAA, may an individual request that a covered entity restrict how it uses or discloses that individual’s protected health information (PHI)? https://www.hhs.gov/hipaa/for-professionals/faq/under-hipaa-may-an-individual-request-that-a-covered-entity-restrict-how-it-uses-or-discloses-that-individuals-protect-health-information/index.html
