Mental Health Insurance Coverage Requirements vs. Actual Access
Most major forms of health coverage include some mental health benefits, but the cleanest way to state it is by plan type: all ACA Marketplace plans cover mental health and substance use services, including psychotherapy and counseling, as essential health benefits.¹⁵ In 2024, 8.2% of Americans were uninsured, meaning roughly 91.8% had some form of health coverage, though benefits and network access still vary widely.⁴
However, having insurance coverage does not guarantee access to timely, affordable care. The following table presents core access metrics based on federal survey data and peer-reviewed claims analysis.
The Mental Health Coverage-to-Access Gap
| Metric | Value | Year/Source |
|---|---|---|
| Americans with health insurance | 91.8% | 2024 CDC NHIS |
| Adults with AMI who did not receive treatment and had perceived unmet need | 21.0% (6.1M people) | 2024 SAMHSA NSDUH |
| Adults with AMI overall who had perceived unmet need | 9.9% | 2024 SAMHSA (computed) |
| Out-of-network rate: psychologist office visits | 18.2% | 2021 claims (RTI) |
| Out-of-network rate: medical/surgical specialist office visits | 1.7% | 2021 claims (RTI) |
| Ratio: psychologist vs. specialist out-of-network use | 10.6x higher | 2021 claims (RTI) |
| CMS Federal Marketplace standard: behavioral health appointment availability | Within 10 business days, ≥90% of time | 2024 CMS policy |
Source: CDC NHIS 2024⁴; SAMHSA NSDUH 2024¹²; RTI International 2024 (analyzing 2021 claims)¹¹; CMS 2024³
Key Finding #1: Most major forms of health coverage include some mental health benefits, but the cleanest way to state it is by plan type: all ACA Marketplace plans cover mental health and substance use services, including psychotherapy and counseling, as essential health benefits.¹⁵ In 2024, 8.2% of Americans were uninsured, meaning roughly 91.8% had some form of health coverage, though benefits and network access still vary widely.⁴
Key Finding #2: In 2024, among adults with Any Mental Illness (AMI) who did not receive mental health treatment, 21.0% reported a “perceived unmet need” (meaning they felt they needed treatment but did not get it). Put differently, that is about 6.1 million people, roughly 9.9% of all adults with AMI.¹²
Key Finding #3: A major insurer-network signal is out-of-network use. In 2021 commercial claims, psychologist office visits were out-of-network 18.2% of the time versus 1.7% for medical/surgical specialist physician office visits, a roughly 10.6x disparity. For psychiatrists specifically, patients were 8.9 times more likely to go out-of-network than for other specialty physicians.¹¹
Wait Times and Network Availability
National “time-to-first-therapy” percentages are not consistently measured in federal surveys, so we avoid quoting an exact “2-week” national rate. Instead, CMS requires Federally-facilitated Exchange plans to meet a behavioral health appointment availability standard of 10 business days at least 90% of the time, verified via secret-shopper surveys.³
In Medicare/Medicaid, a 2025 HHS OIG study found that 45% of surveyed behavioral health providers reported they were not available to treat new patients enrolled in Medicare or Medicaid. Among those who were available, about one-quarter reported wait times longer than 30 days.¹³
Peer-reviewed “secret shopper” studies document significant variation by market and coverage type. In Medicaid managed care directories across four large cities, a 2023 JAMA study found median wait times as high as 64 days in Los Angeles with an interquartile range reaching 126 days, and discussion notes waits extending up to 6 months.¹⁷ For telehealth access at mental health treatment facilities nationally, median wait for first appointment was 14 days, with state variation ranging up to 75 days in Maine.¹⁸
Key Finding: While federal policy establishes a 10-business-day standard for Marketplace plans, real-world access in public coverage programs reveals that nearly half of behavioral health providers are unavailable to new Medicare/Medicaid patients, and among those accepting new patients, one-quarter report waits exceeding 30 days.³ ¹³
The 2026 Premium Surge: Economic Forces Reshaping Coverage
Recent federal budget legislation changes Medicaid and Marketplace affordability on a multi-year horizon, not overnight. Under CBO estimates summarized by KFF, the enacted 2025 reconciliation law reduces federal health care spending by over $1 trillion and is projected to increase the uninsured population by about 10 million, with key effects measured in 2034.⁵ ⁷
Simultaneously, ACA Marketplace enrollees face substantial premium payment increases following the expiration of enhanced tax credits.
Federal Policy Impact on Mental Health Coverage Access
| Policy Change | Scope of Impact | Financial Effect | Source |
| 2025 Reconciliation Law (H.R. 1) | 10 million increase in uninsured | Over $1 trillion reduction in federal health spending | KFF/CBO (2034 endpoint) |
| Specific provision: Medicaid work requirements | 5.3 million increase in uninsured | Part of total above | KFF/CBO (2034 endpoint) |
| ACA Enhanced Premium Tax Credit Expiration | All subsidized Marketplace enrollees | 114% increase in average annual premium payments (net of credits): $888→$1,904 | KFF 2025/2026 |
| Medicaid Reimbursement Gap | Medicaid beneficiaries nationally | Medicaid FFS rates for psychiatry averaged 81.0% of Medicare (2022) | Health Affairs 2024 |
| Gross Marketplace Premium Increases | All Marketplace enrollees | Median proposed increase 18%, average ~20% | KFF Health System Tracker 2026 |
Source: KFF⁵ ⁷ ⁸; Congressional Budget Office⁵; Health Affairs⁶; Peterson-KFF Health System Tracker⁹
Key Finding #1: Recent federal budget legislation changes Medicaid and Marketplace affordability on a multi-year horizon, not overnight. Under CBO estimates summarized by KFF, the enacted 2025 reconciliation law reduces federal health care spending by over $1 trillion and is projected to increase the uninsured population by about 10 million, with key effects measured in 2034.⁵ ⁷
Key Finding #2: If enhanced premium tax credits expire, the biggest consumer impact is on what subsidized enrollees pay out of pocket, not just the sticker price of premiums. KFF estimates average annual premium payments net of tax credits would increase 114% in 2026, from $888 in 2025 to $1,904 in 2026.⁸
Key Finding #3: For those who remain on Medicaid, provider access continues to shrink. In 2022, Medicaid fee-for-service rates for commonly billed psychiatry services averaged 81.0% of Medicare (enrollment-weighted), with large state variation.⁶ Given that commercial insurers already reimburse behavioral health providers at lower rates relative to medical/surgical specialists, Medicaid patients face a compounded access disadvantage.
Key Finding #4: Insurers’ 2026 rate filings frequently cite growth in prescription drug spending, including increased utilization of high-cost drugs such as GLP-1s, as a contributor to premium growth.⁹ These filings do not quantify how such cost pressures translate into mental health reimbursement decisions, so we avoid claiming a direct “budget diversion” mechanism.⁹
The Reimbursement Gap: Mental Health vs. Medical Services
Commercial in-network reimbursement patterns show a persistent valuation gap. The strongest evidence comes from analyzing what commercial insurers actually pay for behavioral health services compared to medical/surgical services, using Medicare as the common benchmark.
In 2021 claims analyzed by RTI International, examining over 22 million individuals’ insurance claims, the following reimbursement patterns emerged:
Commercial In-Network Reimbursement as Percentage of Medicare (2021 Claims)
| Service Category | Average Reimbursement (% of Medicare) | Comparison |
| Medical/surgical specialist physician office visits | 135.3% | Baseline |
| Psychiatrist office visits | 108.4% | Medical/surgical specialists paid ~24.8% higher |
| Psychologist office visits | 105.1% | Medical/surgical specialists paid ~28.7% higher |
| All medical/surgical clinician office visits | 124.8% | Baseline |
| All behavioral health clinician office visits | 102.5% | Medical/surgical clinicians paid ~21.8% higher |
Source: RTI International 2024 (analyzing 2021 commercial insurance claims)¹¹
Key Finding #1: Commercial in-network reimbursement patterns show a persistent valuation gap. In 2021 claims analyzed by RTI, medical/surgical specialist physician office visits averaged 135.3% of Medicare while psychiatrist and psychologist office visits averaged 108.4% and 105.1% of Medicare, respectively.¹¹
Key Finding #2: This reimbursement disparity is consistent across the broader clinician categories: all medical/surgical clinician office visits averaged 124.8% of Medicare versus 102.5% for all behavioral health clinician office visits in 2021, a gap of approximately 21.8%.¹¹
Key Finding #3: Research demonstrates that these reimbursement disparities—documented in the 2024 RTI International study commissioned by the American Psychological Association and the Mental Health Treatment and Research Institute, are a primary driver of the behavioral health provider shortage. Clinicians who can earn higher reimbursement rates for medical/surgical services have less financial incentive to specialize in or remain in behavioral health practice, directly contributing to the network adequacy crisis.¹¹ ²⁰
Time-Based Coding and Documentation Requirements
Psychotherapy codes are explicitly time-based (e.g., CPT 90834 is generally selected for 38–52 minutes; CPT 90837 for 53+ minutes of face-to-face psychotherapy time), and documentation must support the time threshold.² Primary care evaluation and management codes use different time constructs (such as total time on the encounter date for CPT 99213), so strict “per-minute” comparisons across code families are not apples-to-apples and we do not report a single universal discount percent.² ¹
Longer psychotherapy codes carry documentation risk because they are time-threshold codes. CMS guidance specifies that 90837 is reported for 53 or more minutes of face-to-face psychotherapy time and that time must be documented (start/stop or total time).² Payers enforce these time thresholds through audits and denials, and practitioners report billing conservatively to avoid documentation challenges, but we have not identified credible nationwide data quantifying automated downcoding rates or average clawback amounts.
Key Finding: Psychotherapy reimbursement is governed by explicit time thresholds that require precise documentation. While practitioners report audit vulnerability and conservative billing practices, the operational impact should be described in terms of CMS documentation requirements and general audit risk, not unverified claims about nationwide automated systems.²
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The Parity Rollback: Federal Retreat and State-Level Response
In May 2025, the federal Departments of Labor, HHS, and Treasury stated they will not enforce the 2024 MHPAEA Final Rule’s new requirements for failures occurring before the ERIC litigation is resolved plus an additional 18 months, while emphasizing that MHPAEA’s statutory obligations remain in effect.¹⁴
This enforcement pause has shifted primary enforcement responsibility to individual states, creating a patchwork of protections across the country.
Mental Health Parity Enforcement Landscape: 2026
| Enforcement Level | 2026 Status | Source |
| Federal (2024 MHPAEA Final Rule) | New provisions not enforced pending litigation resolution + 18 months; statutory obligations remain | DOL/HHS/Treasury May 15, 2025 |
| New York State | Active enforcement; $2.5M settlement requiring major reforms | NY Attorney General Feb 19, 2026 |
| Maryland | SB0205 passed Senate (43–0), referred to House Health committee | Maryland General Assembly Feb 2026 |
| Remaining States | Enforcement varies widely; many relied on federal framework | APA Services 2026 |
Source: DOL/HHS/Treasury 2025¹⁴; NY Attorney General 2026¹⁰; Maryland General Assembly 2026¹⁶; APA Services 2026²⁰
Key Finding #1: In May 2025, the federal Departments of Labor, HHS, and Treasury stated they will not enforce the 2024 MHPAEA Final Rule’s new requirements for failures occurring before the ERIC litigation is resolved plus an additional 18 months, while emphasizing that MHPAEA’s statutory obligations remain in effect.¹⁴
Key Finding #2: In February 2026, New York Attorney General Letitia James announced a settlement with EmblemHealth requiring major “ghost network” reforms, including appointment access standards (10 business days for initial outpatient behavioral health, 24 hours for urgent needs) and out-of-network protections when timely in-network care is unavailable. The investigation found more than 80% of surveyed listed providers were effectively unavailable, and the settlement includes $2.5 million in penalties plus requirements for provider verification every 90 days and secret shopper surveys.¹⁰
Key Finding #3: States are responding unevenly. For example, Maryland’s SB0205 (a bill to codify certain federal parity requirements in state law) passed the Senate unanimously and was referred to the House Health committee in February 2026, but it should not be described as enacted until final passage and signature.¹⁶ The resulting patchwork means that a patient’s ability to enforce their right to equitable mental health coverage now depends significantly on which state they live in.
Market Consolidation and Network Adequacy
| Factor | Patient Impact | Source |
| Time-based coding requirements | Documentation burden and audit risk for longer sessions | CMS coding guidance |
| Market consolidation trends | Shift toward corporate-affiliated providers in networks | JAMA Psychiatry 2024; APA Services 2026 |
| Rate negotiation disparities | Independent practitioners face competitive pressure | RTI 2024; APA Services 2026 |
| Ghost network enforcement (limited states) | Improved directory accuracy in NY and select enforcement states | NY Attorney General 2026 |
Source: CMS²; JAMA Psychiatry 2024¹⁹; RTI International 2024¹¹; APA Services 2026²⁰; NY Attorney General 2026¹⁰
Key Finding #1: Private equity ownership in outpatient and residential behavioral health is real and uneven, but local market shares vary and should not be asserted without local data. Nationally, PE-owned mental health facilities were estimated at 6.2% of mental health facilities, with several states exceeding 20%.¹⁹
Key Finding #2: As market consolidation continues and larger corporate entities gain greater leverage in rate negotiations with insurers, independent solo practitioners face mounting competitive pressure. This trend may further limit patient access to in-network independent practitioners and reduce patient choice in provider selection.¹¹ ²⁰
Key Finding #3: State-level enforcement actions, such as New York’s $2.5 million settlement against EmblemHealth for maintaining inaccurate provider directories (“ghost networks”), offer a proven model for improving transparency and access. However, these enforcement actions remain limited to a small number of states willing to pursue aggressive oversight and penalties.¹⁰
What This Means for New Yorkers Seeking Therapy in 2026
The data in this report documents a clear and measurable reality: having insurance coverage for therapy and being able to actually use it are two fundamentally different things. All ACA Marketplace plans are required to cover mental health services as essential health benefits,¹⁵ yet in 2021 commercial claims analysis, psychologist office visits were out-of-network 18.2% of the time, 10.6 times the rate for medical/surgical specialist physician office visits.¹¹ Commercial insurers reimbursed behavioral health clinician office visits at an average of 102.5% of Medicare in 2021, compared to 124.8% for medical/surgical clinician office visits.¹¹
Federal enforcement of the 2024 mental health parity regulations has been paused pending litigation,¹⁴ while subsidized Marketplace enrollees face a projected 114% increase in average annual premium payments if enhanced tax credits expire.⁸ Long-term federal budget projections estimate 10 million additional uninsured Americans by 2034 under the enacted 2025 reconciliation law.⁵ ⁷
The RTI International study’s finding that patients seeking behavioral health care were 10.6 times more likely to go out-of-network in 2021 is not merely a statistic—it represents millions of individuals facing impossible choices between their mental health and their financial stability.¹¹
This is the gap that Manhattan Mental Health Counseling exists to close. As a New York-based practice that accepts a wide range of commercial insurance plans and Medicaid, Manhattan Mental Health Counseling operates within the complex reimbursement environment outlined in this report so that clients can focus on what matters: getting better.
In a market where 21.0% of adults with mental illness who did not receive treatment reported a perceived unmet need in 2024,¹² and where the evidence shows persistent out-of-network disparities and reimbursement gaps,¹¹ Manhattan Mental Health Counseling maintains a model built around accessibility, continuity, and real therapeutic depth. Clients are matched with licensed therapists and supported through ongoing care, with both in-person and telehealth options available throughout New York State.
If you are navigating the insurance landscape described in this report and wondering whether your benefits can actually connect you with quality therapy, Manhattan Mental Health Counseling can help you determine your coverage and get started.
Sources
- Centers for Medicare & Medicaid Services (CMS). “Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).” October 31, 2025. Available at: cms.gov/medicare/physician-fee-schedule.
- Centers for Medicare & Medicaid Services (CMS). “Psychotherapy Services – Reporting Time.” Article ID A57520, Version 43. Available at: cms.gov/medicare-coverage-database.
- Centers for Medicare & Medicaid Services (CMS). “Appointment Wait Time and Secret Shopper Survey Technical Guidance for QHP Issuers in the FFE.” 2024. Available at: qhpcertification.cms.gov.
- Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2024.” June 24, 2025. Available at: cdc.gov/nchs/pressroom.
- Congressional Budget Office (CBO). Budget impact estimates for 2025 reconciliation law. Summarized by KFF. 2025.
- Holgash, Karyn, and Martha Heberlein. “Physician Acceptance of New Medicaid Patients.” Health Affairs, January 2024. Available at: healthaffairs.org.
- KFF (Kaiser Family Foundation). “Health Provisions in the 2025 Federal Budget Reconciliation Law.” 2025. Available at: kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/.
- KFF (Kaiser Family Foundation). “ACA Marketplace Premium Payments Would More Than Double on Average Next Year if Enhanced Premium Tax Credits Expire.” 2025. Available at: kff.org/affordable-care-act/aca-marketplace-premium-payments-would-more-than-double/.
- Peterson-KFF Health System Tracker. “How Much and Why ACA Marketplace Premiums Are Going Up in 2026.” January 2026. Available at: healthsystemtracker.org/brief/how-much-and-why-aca-marketplace-premiums-are-going-up-in-2026/.
- New York Attorney General. “Attorney General James Secures Sweeping Reforms Improving Access to Mental Health Care from EmblemHealth.” Press Release, February 19, 2026. Available at: ag.ny.gov/press-release/2026/attorney-general-james-secures-sweeping-reforms-improving-access-mental-health.
- RTI International. “Behavioral Health Parity – Pervasive Disparities in Access to In-Network Care Continue.” Tami Mark, Ph.D., M.B.A., and William Parish, Ph.D., M.A. April 2024. Commissioned by Mental Health Treatment and Research Institute with partial funding from American Psychological Association. Available at: rti.org/publication/behavioral-health-parity-pervasive-disparities-access-network-care-continue/.
- Substance Abuse and Mental Health Services Administration (SAMHSA). “2024 National Survey on Drug Use and Health (NSDUH): Annual National Report.” U.S. Department of Health and Human Services, Rockville, MD. 2025. Available at: samhsa.gov/data/report/2024-nsduh-annual-national-report.
- U.S. Department of Health and Human Services, Office of Inspector General. “Availability of Surveyed Behavioral Health Providers to Treat New Patients Enrolled in Medicare and Medicaid.” Report, 2025. Available at: oig.hhs.gov/reports/all/2025/availability-of-surveyed-behavioral-health-providers/.
- U.S. Department of Labor, Employee Benefits Security Administration; U.S. Department of Health and Human Services; U.S. Department of the Treasury. “Statement Regarding Enforcement of the Final Rule on Requirements Related to the Mental Health Parity and Addiction Equity Act.” May 15, 2025. Available at: dol.gov/agencies/ebsa/laws-and-regulations/laws/mental-health-parity/.
- HealthCare.gov. “Mental Health and Substance Abuse Coverage.” U.S. Centers for Medicare & Medicaid Services. Available at: healthcare.gov/coverage/mental-health-substance-abuse-coverage/.
- Maryland General Assembly. “SB0205 – Mental Health Parity and Accountability Act of 2026.” 2026 Regular Session. Available at: mgaleg.maryland.gov/mgawebsite/Legislation/Details/sb0205?ys=2026RS.
- Busch, Susan H., et al. “Behavioral Health Appointment Availability in Medicaid Managed Care Networks.” JAMA, vol. 330, no. 18, 2023. Available at: jamanetwork.com/journals/jama/fullarticle/2821639.
- Cantor, Joel H., et al. “Telehealth Access at Mental Health Treatment Facilities: National and State Estimates.” Journal of Substance Use and Addiction Treatment, 2024. Available at: pmc.ncbi.nlm.nih.gov/articles/PMC10837750/.
- Zhu, Jane M., et al. “Private Equity Ownership of US Mental Health Facilities.” JAMA Psychiatry, 2024. Available at: jamanetwork.com/journals/jamapsychiatry/fullarticle/2818048
- American Psychological Association Services. “New Policies Affecting Access to Mental Health Care.” January 2026. Available at: updates.apaservices.org.
