Open Enrollment 2027: Picking a Plan That Pays for Psychiatry

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Open enrollment is the one time each year you choose how your mental health care gets paid for. The plan you pick this fall decides whether a psychiatrist or therapist you choose in 2027 costs you a share of each visit or the whole thing. Across 170 out-of-network psychiatry visits by 36 of our patients between October 2024 and July 2026, plans paid back a median of about $200 per visit, and 23% of visits paid nothing. Both numbers trace back to choices made at enrollment.

More people need mental health care than a decade ago

In federal survey data, the share of Americans 12 and older with depression in the past two weeks rose from 8.2% in 2013–2014 to 13.1% in August 2021 to August 2023. In 2022, an estimated 23.1% of U.S. adults, 59.3 million people, had a mental illness. The World Health Organization estimated that global prevalence of anxiety and depression rose 25% in the first year of COVID-19. Among U.S. high school students, persistent sadness or hopelessness went from 30% in 2013 to 42% in 2021, and stood at 40% in 2023.

Several current pressures likely add to that load. Rapid change at work is one: in the American Psychological Association's 2023 Work in America survey, 38% of workers worried that AI might make some or all of their job duties obsolete, and 51% of those workers said their job hurt their mental health, compared with 29% of workers without that worry. Childhood is changing too. A 2025 Common Sense Media survey found that 72% of teens had used an AI companion at least once, and the APA's 2025 health advisory warned that these relationships "may displace or interfere with the development of healthy real-world relationships" during a period of rapid brain development. Add the gaps many families feel between Gen Z and older generations, and the strain is easy to see. These are survey associations, and they can't establish that AI causes mental illness. They are plausible stressors, and we should take them seriously.

Stress matters clinically because it can tip vulnerable people into more serious illness. It can bring on or worsen anxiety, depression, ADHD-related impairment, and post-traumatic stress. In people with bipolar disorder, a meta-analysis of 42 studies found more stressful life events before relapse. A meta-analysis of life events and psychosis found roughly three times the odds of psychosis after adverse life events (OR 3.19). And in prospective studies of people with major depression followed for 12 to 18 years, 22.5% went on to develop bipolar disorder, with the highest risk in the first five years. Early, steady care is how we catch those turns.

Psychiatric care moved from state hospitals to the private office

For much of the 20th century, serious mental illness in the U.S. was treated in large state institutions. People with the most severe illness often lived there for years, and others stayed for months of intensive treatment before going home, a model closer to a long inpatient stay than to outpatient care. The resident population of state and county mental hospitals peaked in 1955 at about 559,000.

It was dismantled for two reasons. The first was how people were treated inside it. Institutional neglect became a public scandal; the best-known case, the 1972 television exposé of Willowbrook State School in New York, involved a state institution for people with intellectual disabilities, and it helped change how the public saw institutional care generally. The second was money. President Kennedy signed the Community Mental Health Act on October 31, 1963, to replace institutions with community mental health centers. Only about half of the planned centers were ever built, and none was fully funded. Medicaid, enacted in 1965, also excluded most adult care in "institutions for mental disease," leaving that cost to the states. Researchers have described the unintended result as a generation of people with severe mental illness who are homeless or criminalized.

What filled the space was outpatient care, and much of it is paid out of pocket.

Your plan covers mental health on paper, and finding an in-network psychiatrist is harder

Federal parity law, the Mental Health Parity and Addiction Equity Act of 2008, requires plans to cover mental health and substance use care in a similar way to medical and surgical care. Access is a separate problem. In national data from 2009–2010, 55.3% of psychiatrists accepted private insurance, compared with 88.7% of physicians in other specialties, and the share had fallen 17% since 2005–2006. In the Northeast it was 48.5%.

Directories overstate what's available. In a 2023 secret-shopper study by U.S. Senate Finance Committee staff, callers tried to book with 120 listed mental health clinicians across 12 Medicare Advantage plans in six states. About 80% of the listings were "ghosts," clinicians who were unreachable, not in network, or not taking new patients, and callers got an appointment only 18% of the time. That study covered Medicare Advantage; commercial directories have the same reputation.

Visit length is the other problem. Between 1996–1997 and 2004–2005, the share of office-based psychiatrist visits that included psychotherapy fell from 44.4% to 28.9%, and shorter medication visits likely took its place. In my clinical view, even a highly stable patient should get at least 20 minutes face to face with their psychiatrist, and more if they take a controlled substance, because there is more than 20 minutes of material to cover: symptoms, side effects, sleep, substance use, safety, and how life is going. That's my standard as a physician; no regulation sets it.

Out of network means "see who you want, send us the bill, and we'll split it"

That's the plain version of what an out-of-network benefit promises. You pick any licensed clinician. You pay the visit, the practice gives you a superbill, and you send it to your plan. The plan then pays its share.

The split has three moving parts. First, nothing is paid until you meet the out-of-network deductible. Second, the plan pays a percentage of its own allowed amount, the price it decides the service is worth, which is often less than the practice's fee. Third, you pay the coinsurance, the rest of the allowed amount, plus any difference between the allowed amount and the fee. HealthCare.gov's example of out-of-network coinsurance is 40%, meaning the plan pays 60% of the allowed amount. Where our patients' remittances stated a coinsurance, the median was 30%, so the plan paid 70%. If a plan has an out-of-network out-of-pocket limit and you reach it, the plan pays 100% of its allowed amount for the rest of the year. Plans aren't required to count out-of-network spending toward the limit, so check that line.

Open enrollment is a chance to invest in your mental health for 2027

A plan with out-of-network benefits usually costs more in premium. It pays off if you use it: weekly psychotherapy, or psychiatry visits every two weeks or monthly. For someone who expects that level of care, the premium buys the freedom to choose the clinician.

Fit matters. A meta-analysis of 295 studies covering more than 30,000 patients found a consistent association between the strength of the patient-therapist alliance and treatment outcome (r = .278). Finding the right person is a little like dating. You're looking for a good match for where you are at that point in your life, and it may not be forever. A plan that lets you see whoever you need makes that search possible.

The plan type decides whether out-of-network psychiatry is covered at all

HealthCare.gov defines an EPO as a plan that covers services only from doctors and hospitals in its network, except in an emergency, and says an HMO generally won't cover out-of-network care outside an emergency. A PPO lets you see doctors outside the network at additional cost. A POS plan usually needs a primary care referral to see a specialist.

Parity rules follow the same line. Under 29 CFR 2590.712, "outpatient, out-of-network" is its own benefit classification. A plan that pays for an out-of-network orthopedist generally owes you out-of-network psychiatry too, and an EPO that pays for no out-of-network medical care owes none for psychiatry. The NYC PPO plan directory sorts which similarly named products carry an out-of-network benefit.

Four lines on the SBC decide what a year of visits costs

Every plan must give you a Summary of Benefits and Coverage (SBC), a standardized plain-language summary, with enrollment materials or at least 30 days before the plan year when re-enrollment is automatic. Put the SBCs for each plan side by side and read four lines.

The fourth line is the one people skip. On a $100 allowed amount, 40% coinsurance means the plan pays $60. If a second plan sets the allowed amount much lower, a better coinsurance percentage can still pay you less per visit.

An HDHP with an HSA suits some patients, and a PPO suits others

A high-deductible health plan (HDHP) lets you fund a health savings account (HSA). IRS Publication 502 lists psychiatric care as a qualified medical expense, so HSA dollars can pay an out-of-network psychiatrist, and since Public Law 119-21 an HDHP may cover telehealth before the deductible without losing HSA eligibility, though plans aren't required to. An HDHP may or may not include out-of-network benefits, so confirm that first.

The HDHP tends to win when it has out-of-network benefits and you can fund the HSA; the PPO tends to win when its out-of-network deductible is low enough that regular visits clear it early in the year. Do the arithmetic with each SBC's deductible and coinsurance against the premium difference.

State and federal protections, and where they stop

New York's 10-business-day rule. Network adequacy rules adopted in 2025 entitle New Yorkers in qualifying plans to an initial behavioral health appointment within 10 business days. When an insurer can't meet that in network, it has to cover an out-of-network clinician without raising your cost-sharing. For commercial plans the standards apply as policies are renewed, modified, or purchased on and after July 1, 2025. The Department of Financial Services has stated that ERISA preempts state jurisdiction over self-funded employer plans, so ask HR whether each plan is fully insured or self-funded.

The No Surprises Act. Its balance-billing protections cover most emergency care, non-emergency care from out-of-network clinicians at certain in-network facilities, and air ambulance services. An office visit with an out-of-network psychiatrist you chose falls outside them, so plan choice is your protection. If you're uninsured or paying without insurance, you have a right to a written good faith estimate.

The 2027 enrollment windows in the states we serve

Marketplace dates are set by each exchange. Employer plans set their own windows, and HR is the only reliable source for yours.

Outside open enrollment, a qualifying event can reopen enrollment. For employer group plans, federal rules give you at least 30 days after losing other coverage, marrying, or having or adopting a child to request enrollment. Some employer plans have their own pages here: Google's gPPO, Meta's plans, NYU's Advantage plan, and the Empire Plan.

What real reimbursements look like

The examples below come from insurer remittances and Explanations of Benefits (EOBs) for our patients in 2025. Each one is a single claim line, one CPT code from one visit, shown on its own; none of them is one person's treatment history. Every identifier is removed, the date is shown as a year only, and paid amounts are rounded to the nearest $10. The practice's fees and the plans' allowed amounts are left out on purpose. These are illustrations of how plans behave, and they can't predict what your plan will do.

In aggregate, the per-visit median paid back was about $220 on Anthem / Empire BCBS (20 patients) and about $200 on UnitedHealthcare Choice Plus (13 patients). The full table is in the out-of-network reimbursement guide; it's a small sample from one practice.

Payment varies by insurer, by plan, and by ZIP code

Two people with the same insurer can get very different checks for the same visit. Examples 2 and 3 above are the same insurer and the same product name, with allowed amounts set from two different benchmarks. Within one company, each employer's plan sets its own deductible, coinsurance, and allowed-amount method.

Geography adds a third layer. FAIR Health, an independent nonprofit whose charge data some insurers use for out-of-network payment, groups its data into 493 "geozips," areas typically based on the first three digits of a ZIP code. Medicare adjusts its physician fees through geographic practice cost indices across 109 payment localities (as of 2024), and some plans pay out of network as a percentage of Medicare; FAIR Health's consumer guide gives "130 percent of the rate Medicare would normally pay" as an example. Which location counts, and which benchmark applies, depends on the plan, and few plans explain it.

That opacity is the reason for this article. If more people can see how these plans actually pay, more people can pick the plan that fits the care they need, and hold their plan to what it promised.

One more thing

I built a free directory called OpenShrink, because finding a clinician shouldn't mean guessing. It lists licensed therapists, psychiatrists and other mental health clinicians across the U.S., drawn from the federal registry. Search by city or ZIP and see each person's credentials and office. It's an early preview, and I'm building it to learn more about each clinician's strengths over time, including from what people tell us worked for them. It doesn't know who takes your insurance or who has openings, so call and ask. (Yes, I'm listed in it too.)

Related

How out-of-network reimbursement works · The benefits call, question by question · NYC PPO plan names decoded · Superbills explained · What out-of-network care costs

Frequently Asked Questions

What does out of network mean for psychiatry?

You can see any licensed clinician, pay the visit, and send the superbill to your plan. After you meet the out-of-network deductible, the plan pays a percentage of its own allowed amount, which is often less than the practice's fee.

How much does a plan pay for an out-of-network visit?

It pays a percentage of its allowed amount after the out-of-network deductible. HealthCare.gov's example of out-of-network coinsurance is 40%, meaning the plan pays 60% of the allowed amount. Where our patients' remittances stated a coinsurance, the median was 30%, so the plan paid 70%.

Does an EPO plan cover an out-of-network psychiatrist?

Generally no. HealthCare.gov defines an EPO as covering services only from doctors and hospitals in its network, except in an emergency. An HMO generally won't cover out-of-network care outside an emergency either. PPO and POS plans typically include out-of-network benefits.

Which lines on the Summary of Benefits and Coverage matter for out-of-network psychiatry?

Four: the out-of-network deductible, the out-of-network coinsurance, the out-of-network out-of-pocket limit, and how the plan sets its allowed amount. Coinsurance is a percentage of the allowed amount, never of the fee the practice charges.

Why can the same visit pay differently on two plans from the same insurer?

Each employer's plan sets its own deductible, coinsurance, and allowed-amount method, and allowed amounts can come from different benchmarks, such as a database of local fees or a percentage of Medicare. Benchmarks are often set by geographic area.

When is open enrollment for 2027 in New York?

On NY State of Health, open enrollment for 2027 coverage runs November 1, 2026 through January 31, 2027, and enrolling by December 15, 2026 gets coverage starting January 1, 2027. Employer plans set their own windows, so check with HR.

Can I use an HSA to pay an out-of-network psychiatrist?

Yes. IRS Publication 502 lists psychiatric care as a qualified medical expense. Since Public Law 119-21, an HDHP may also cover telehealth before the deductible without losing HSA eligibility, though plans aren't required to.

Does the No Surprises Act protect me if I choose an out-of-network psychiatrist?

Its balance-billing protections cover most emergency care, non-emergency care from out-of-network clinicians at certain in-network facilities, and air ambulance services. An office visit with an out-of-network psychiatrist you chose falls outside them. If you're uninsured or paying without insurance, you have a right to a written good faith estimate.

Do New York's 10-business-day appointment rules apply to my employer plan?

Only if the plan is New York-regulated. The Department of Financial Services has stated that ERISA preempts state jurisdiction over self-funded employer plans, so ask HR whether a plan is fully insured or self-funded.

Sources

All accessed October 30, 2026.

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