Empire Plan Out-of-Network Benefits for Psychiatric Care

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New York State employees hold one of the stronger out-of-network mental health benefits I have seen in practice, and most of the state workers I meet have no idea. Under the 2026 Empire Plan At A Glance, once you meet a $1,250 combined annual deductible, the plan pays 80% of its allowed amount for outpatient visits to a non-network psychiatrist. The allowed amount is set at 275% of Medicare rates.

That last number is the one that matters. Commercial insurers commonly set allowed amounts far below Manhattan private-practice fees, which is how "70% coverage" turns into a $140 check; I walk through that arithmetic on the out-of-network cost page. The Empire Plan publishes its basis in its own plan documents. I'm a psychiatrist, not a billing advocate, and every figure on this page traces to a document published by the NYS Department of Civil Service. They're all linked at the bottom so you can read them yourself.

Who has this benefit

The Empire Plan is the main option under NYSHIP, the New York State Health Insurance Program. It covers employees of New York State agencies in the CSEA, PEF, M/C, and UUP (SUNY) groups, each of which has a 2026 At A Glance with identical non-network mental health terms, and it continues into retirement for eligible state retirees. Beyond direct state employment, many local governments, school districts, libraries, fire districts, public authorities, and quasi-public organizations participate in NYSHIP as Participating Agencies or Participating Employers. New York City itself cannot participate under Civil Service Law, per the 2023 NYSHIP General Information Book.

Research foundations attached to state institutes are a group worth naming, since many of their employees don't realize they're NYSHIP members. The Research Foundation for Mental Hygiene, which employs research staff at the New York State Psychiatric Institute, participates in NYSHIP as a Participating Employer; its own open enrollment materials for the 2024 plan year describe the Empire Plan's five parts and list Carelon as the mental health administrator. If you work for a research foundation and carry an Empire Plan card, everything on this page is about your insurance.

Two caveats before the numbers. If you chose a NYSHIP HMO instead of the Empire Plan at option transfer, none of this applies to you. And if your employer offers the Excelsior Plan, a lower-cost NYSHIP variant, the terms differ; check the documents for your own group.

Network and non-network, in plain terms

The Empire Plan's Mental Health and Substance Use Program is administered by Carelon Behavioral Health, the company known as Beacon Health Options until March 2023. It runs two tiers.

Network: you pay a $25 copayment per outpatient visit, in person or telehealth, with no deductible and no coinsurance. If a network psychiatrist fits your needs and actually has availability, that is the cheaper path, and Carelon's Clinical Referral Line will find one for you around the clock. The plan also guarantees network-level benefits if no network provider is available in your area and you arrange care through that line.

Non-network: you can see any licensed psychiatrist you choose, including this practice, and the plan reimburses you on the following terms, from the 2026 At A Glance and the 2025 Empire Plan Certificate:

• Deductible: a $1,250 combined annual deductible each for the enrollee, the enrolled spouse or domestic partner, and all dependent children together; it drops to $625 for employees in or equated to salary grade 6 or below. The deductible is shared with the Basic Medical Program, so out-of-network medical bills from earlier in the year may already have chipped away at it.
• Coinsurance: after the deductible, the plan pays 80% of the allowed amount or the actual billed charge, whichever is less. You pay the remaining 20% plus anything your psychiatrist charges above the allowed amount.
• The cap: your coinsurance counts toward a $3,750 combined annual maximum ($1,875 at grade 6 or below). Once you reach it, the plan pays 100% of the allowed amount for the rest of the year.
• No visit limit: the Certificate states that coverage for medically necessary outpatient mental health care is unlimited.

The allowed amount decides everything

The 2025 Empire Plan Certificate defines the allowed amount for non-network mental health providers precisely: 275% of the rates published by the Centers for Medicare and Medicaid Services for the same or similar service within the geographic market. When CMS publishes no rate for a service, Carelon applies a gap methodology; when neither applies, the allowed amount falls to 20% of the billed charge.

For comparison, the plan's own 2026 Out-of-Network Reimbursement Disclosure shows the medical program using FAIR Health's 80th percentile as its benchmark, and typical commercial plans benchmark far lower still. A multiple of 2.75 times Medicare is a generous basis, and it is the reason an Empire Plan member's effective coverage for private psychiatry can land dramatically higher than a commercial PPO member's. Whether 275% of Medicare reaches your psychiatrist's full fee depends on the specific service code and the fee; sometimes it covers most of the charge, sometimes less. Carelon will quote you the actual dollar figure for a given CPT code before you book, and the At A Glance tells you to do exactly that.

What the arithmetic looks like

An illustration, with the plan's verified percentages and a hypothetical allowed amount. Say your psychiatrist charges $450 for a follow-up visit with psychotherapy, and Carelon quotes you a $400 allowed amount for that service code. (The $400 is illustrative; the real number comes from Carelon, and you should get it before your first visit.)

Charged fee:                       $450
Carelon's allowed amount:          $400   (get the real figure: 1-877-769-7447, press 3)

After the $1,250 deductible is met:
Plan reimburses:                   $320   (80% of $400)
You pay:                           $130   ($80 coinsurance + $50 above the allowed amount)
Effective coverage:                 71%   of the charged fee

Two features improve on that picture over a full year. First, every coinsurance dollar counts toward the $3,750 annual maximum, and once you cross it the plan pays 100% of the allowed amount. Second, the $1,250 deductible is combined across programs, so it is met once, and weekly treatment meets it quickly. In other words, the worst months are the first ones; the benefit gets stronger the longer treatment runs.

Call before the first appointment

The benefit comes with a real precondition, and skipping it is the expensive mistake. From the 2025 Empire Plan Certificate:

"Prior to using any Non-Network Services, You are responsible for contacting the Clinical Referral Line by calling The Empire Plan and choosing the MHSU Program... to obtain MHSU Program Precertification for care obtained from a Non-Network Provider."

Carelon must also certify all covered services as medically necessary, network or not; the Certificate is blunt that uncertified treatment receives no benefits at all. The 2026 At A Glance frames the same requirement as calling before you seek services "to receive the highest level of benefits and avoid possible penalties." Accordingly, make one phone call before your first visit: 1-877-769-7447, press or say 3, tell them you plan to see a non-network psychiatrist, and ask them to set up precertification. It takes minutes and it protects everything above.

The paperwork is a superbill

Out-of-network practices, mine included, don't bill Carelon. You pay at the time of the visit and receive a superbill, an itemized receipt carrying the CPT service codes, diagnosis codes, and the provider's NPI that a claim requires. You submit it with a claim form, and reimbursement comes to you once the deductible is met. The full mechanics, including what must appear on the document and how to submit, are on the superbill page. My practice issues one after every visit.

Confirm your own numbers before you book

Plan terms are negotiated by group and change by year, so treat this page as a map rather than a quote. The general benefit-check script applies to any insurer; for the Empire Plan specifically, call 1-877-7-NYSHIP (1-877-769-7447), press 3 for Carelon, and ask these questions:

1. "Am I enrolled in The Empire Plan or in a NYSHIP HMO?" (If you're unsure, your agency's Health Benefits Administrator can tell you.)
2. "What is the allowed amount for CPT code [ask the practice which codes it bills] in ZIP code 10011?"
3. "How much of my combined annual deductible have I met this year?"
4. "I plan to see a non-network psychiatrist. Can we complete precertification now?"
5. "Where do I send claims, and do I need a claim form beyond the superbill?"

If you're at salary grade 6 or below, ask whether the reduced $625 deductible and $1,875 coinsurance maximum apply to you.

What my practice offers Empire Plan members

I'm an out-of-network psychiatrist, which is precisely the situation this benefit was written for. I see patients in person at Integrative Psych, 80 Eighth Avenue in Chelsea, and by telehealth anywhere in New York State under license #275559, which matters for state workers in Albany, Buffalo, Rochester, Syracuse, and everywhere between. Visits are 30 to 60 minutes, medication and psychotherapy are handled by the same clinician, and a superbill follows every appointment.

The clinical work spans ADHD evaluation and treatment, depression, anxiety, and psychiatric medication management, in adults, adolescents, and children. Whether an out-of-network psychiatrist is worth it depends on the complexity of what you're bringing; for a straightforward presentation, Carelon's network at $25 a visit is a genuinely good deal, and I'd tell you to use it.

Read the documents yourself

Every number above comes from one of these NYS Civil Service publications:

• 2026 Empire Plan At A Glance (PEF edition; the CSEA and UUP editions carry the same mental health terms)
• 2025 Empire Plan Certificate, Section IV: Mental Health and Substance Use Program
• 2026 Out-of-Network Reimbursement Disclosures
• 2023 NYSHIP General Information Book

Frequently Asked Questions

Does the Empire Plan cover out-of-network psychiatrists?

Yes. Under the 2026 Empire Plan At A Glance, non-network outpatient mental health care is covered at 80% of the allowed amount after a $1,250 combined annual deductible, and your coinsurance is capped at a $3,750 annual maximum, after which the plan pays 100% of the allowed amount. Medically necessary outpatient visits carry no annual limit.

Who runs the Empire Plan's mental health program?

Carelon Behavioral Health, the company known as Beacon Health Options until March 2023, administers the Empire Plan Mental Health and Substance Use Program. Reach it at 1-877-769-7447; press or say 3.

Do I need approval before seeing a non-network psychiatrist?

The 2025 Empire Plan Certificate makes you responsible for contacting the Clinical Referral Line for precertification before using non-network services, and Carelon must certify care as medically necessary for any benefits to be paid. One phone call before the first appointment protects the benefit.

How is the Empire Plan allowed amount calculated for mental health visits?

At 275% of the rates published by the Centers for Medicare and Medicaid Services for the same or similar service in your geographic market. When CMS publishes no rate for a service, Carelon applies a gap methodology, and when neither applies the allowed amount is 20% of the billed charge. Both the 2026 At A Glance and the 2025 Certificate state this.

I work for SUNY or a local government. Does this apply to me?

SUNY employees represented by UUP have the same 2026 numbers, as do the CSEA, PEF, and M/C groups. Many local governments, school districts, public authorities, and research foundations (including the Research Foundation for Mental Hygiene at NYSPI) participate in NYSHIP as Participating Agencies or Participating Employers, though New York City itself cannot participate under Civil Service Law. Retirees keep NYSHIP coverage. Check the At A Glance published for your specific group before relying on any figure here.

Is Dr. Sultan in the Empire Plan network?

No. The practice is out-of-network with all insurance, which is the situation the Empire Plan's non-network benefit exists for. If you would rather use the network, Carelon's Clinical Referral Line will locate a network provider and your cost is a $25 copayment per visit.