Out-of-network benefits let your health plan pay for part of the care you get from a clinician outside its network. In the usual arrangement, you pay the clinician, the claim goes to your plan, and once you meet a separate out-of-network deductible the plan reimburses a share of what it considers an allowed amount. That allowed amount is often lower than the clinician’s fee, and you owe the difference.
Part of our guide: Getting Started With Mental Health Care
Whether this is worthwhile depends on three numbers specific to your plan: your deductible, your coinsurance and the allowed amount. Most New York regulated plans must give you an estimate on request, so you can work it out before you commit. This article explains general rules and is not legal or financial advice.
First: do you have these benefits at all?
The plan type on your card, which New York says should show your coverage type, such as POS, HMO, EPO, PPO or fee-for-service, is a first clue.
- PPO: you pay less using network providers but can generally go outside the network at extra cost.
- HMO: generally won’t cover out-of-network care except in an emergency.
- EPO: services are covered only if you go to providers in the plan’s network, except in an emergency.
- POS and others: rules vary, so ask your plan.
The clue is not the final answer. Your Certificate of Coverage governs, and you can request it from your plan or your employer’s benefits manager. Medicaid and Medicare work differently and are outside this article. Mind Body Seven does not accept Medicare or Medicaid, including managed Medicaid.
How the payment works, step by step
- The charge. The clinician sets a fee. Your plan does not control it.
- The allowed amount. Your plan decides what it recognizes for that service. New York’s Department of Financial Services (DFS) says there is no standard method for determining out-of-network payments, and each plan sets its own.
- The deductible. DFS explains that out-of-network services have a separate deductible, often higher than the in-network one, and that only the allowed amount counts toward it.
- Coinsurance. After the deductible, you may owe a percentage of the allowed amount.
- The balance. You are responsible for the difference between the billed charge and the allowed amount.
DFS uses this example: a provider charges $1,000 and the plan’s allowed amount is $200, so you pay the $800 difference plus any coinsurance. That is DFS’s illustration of the math, not a typical therapy fee. The lesson is that the allowed amount can matter as much as the percentage.
What New York adds
The right to an estimate
This is the most useful tool. Most New York regulated plans must, on request, provide an approximate dollar amount they will reimburse for a specific out-of-network service. Without billing codes, the plan may give a range, so ask the clinician’s office which codes apply. Under Insurance Law 3217-a, that figure is not binding and can change, so treat it as an estimate. DFS’s list of consumer rights also includes learning how your plan’s payment compares to the usual cost of out-of-network services and how to estimate what you will pay.
An 80 percent option exists, but not everyone has it
Insurance Law 3241 requires insurers and HMOs issuing comprehensive group policies that cover out-of-network services to make available, if the policyholder or contract holder requests it, at least one option covering at least 80 percent of the “usual and customary” cost of out-of-network services, after any deductible. The statute defines that cost as the 80th percentile of charges for the service in the area. It addresses group coverage, the policyholder is often an employer, and the option has to be requested, so do not assume your plan includes it. Your Certificate of Coverage will show what yours pays.
Network gaps
This is the important exception. New York requires that networks be adequate to meet the health and mental health needs of insureds. If an insurer offering a managed care product determines it has no provider with the right training and experience for your needs, it must refer you to an appropriate provider at no additional cost beyond what you would pay in network, under a treatment plan the insurer approves.
This generally requires approval before care begins. If the plan denies the referral, it must explain why and name in-network providers. You can appeal, with a written statement from your attending physician saying in-network providers lack the necessary training and experience, and that an appropriate out-of-network provider is available. If you have called listed in-network clinicians and found none who treat your condition, keep notes of who you called and when.
Does your plan fall under New York rules?
Many of these protections apply only to state-regulated coverage. DFS says that if the patient is covered by a self-funded plan or Medicare, DFS lacks jurisdiction to assist. Some employers self-fund their plans. A card with the phrase “fully insured coverage” indicates a state-regulated plan. If you are unsure, ask your employer’s benefits team.
Federal rules: what they do and don’t do
The federal parity law generally says that financial requirements and treatment limits for mental health benefits cannot be more restrictive than those for most medical and surgical benefits in the same classification, and it treats outpatient out-of-network benefits as their own classification. If a group plan covers out-of-network medical care, it needs to include out-of-network providers for mental health care too. Group plans of small employers fall under different federal rules. Parity does not mean your plan pays a clinician’s full fee.
Surprise-billing laws usually will not help with a planned visit you chose. Federal protections don’t apply at settings like a doctor’s office that isn’t a hospital outpatient department. New York’s own surprise bill law covers certain referrals by in-network doctors when you did not sign written consent, so ask DFS if you think this fits your case.
In-network or out-of-network: how to compare
| Question | In network | Out of network |
|---|---|---|
| What you pay at the visit | Usually a copay or coinsurance | Often the full fee, unless the office arranges otherwise |
| Paperwork | Handled by the clinician | Sometimes filed for you, sometimes yours |
| Yearly cost limit | Plan’s in-network limit | Ask whether a separate limit applies |
| Choice of clinician | Limited to the directory | Wider, including those outside any network |
To estimate the out-of-network cost: find your remaining deductible, get the approximate allowed amount, apply your coinsurance, and add the gap between fee and allowed amount. Then ask how many visits you expect over a year. Early visits often cost more because of the deductible.
Write down the answers, the date and any call reference number. Payment rules can change at renewal, so a note made this year may not hold next year.
For some people the numbers will favor in-network care, especially for weekly therapy on a tight budget. For others, a specific expertise, a clinician they trust or an in-network wait may make the higher cost worth it. Both are reasonable choices. A list of exact wording to use on the call is in questions to ask your insurer.
How this works at Mind Body Seven
Mind Body Seven is an out-of-network practice. For many clients with Cigna, Aetna or BCBS plans, the practice files out-of-network claims for them. For other carriers, such as UnitedHealthcare, superbills are available in the patient portal so clients can submit claims themselves; see what a superbill is. Clients who are uninsured or not using insurance can request a Good Faith Estimate.
Current fees and details are on our fees and insurance page, and you can read more on our out-of-network psychiatry page. For an integrative angle, see whether integrative psychiatry is covered.
FAQs
Does out-of-network care count toward my regular deductible?
Usually not. New York regulators describe a separate out-of-network deductible, and only the allowed amount counts toward it. Your Certificate of Coverage will confirm how yours works.
Can my plan change its out-of-network payment?
Yes. DFS notes that a plan’s approach may change at annual renewal, so it is worth reviewing your Certificate of Coverage each year.
What if the plan denies my request for an out-of-network clinician?
You generally have 180 days for an internal appeal. If it is upheld, New York offers an external appeal for eligible denials in state-regulated plans, generally within four months of the final denial. Follow the deadlines in your denial letter, and see our superbill guide for claim-level denials.
