Medicaid and Private-Pay Psychiatry: What New York Patients Should Know

In New York, a psychiatrist who accepts you as a Medicaid patient must bill Medicaid or your Medicaid Managed Care plan and may not ask you for payment beyond any applicable Medicaid copayment. A practice can charge you directly only if you and the practice agree, before the service, that you are being seen as a private-pay patient, and that agreement must be mutual and voluntary. When you choose private pay, Medicaid cannot be billed for those services, so there is no reimbursement afterward.

That makes Medicaid different from employer insurance, where an out-of-network visit can still be partly reimbursed. This guide explains the payment rules, how Medicaid Managed Care plans must handle gaps in their networks, a prescription rule that catches many people out, and how to decide between in-network care and paying privately. It is general information, not tax or legal advice.

The basic rule: Medicaid payment is payment in full

Federal law requires each state to limit Medicaid participation to providers who accept the Medicaid payment, plus any deductible, coinsurance or copayment the program requires, as payment in full. New York's Medicaid provider manual applies that rule to everyday practice. When a provider accepts a Medicaid enrollee as a patient, the provider agrees to bill Medicaid, or the enrollee's Managed Care plan for services the plan covers, and is prohibited from requesting any other payment from the enrollee or a responsible relative except applicable copayments.

The protection holds even when billing goes wrong. The manual says the prohibition on charging the enrollee still applies when a participating provider fails to submit a claim on time, or when a claim is denied for any reason other than the patient not being eligible on the date of service. A provider that has accepted you as a Medicaid patient also may not send unpaid bills to a collection agency, apart from Medicaid copayments.

What this means in practice

• If a psychiatrist accepted you as a Medicaid patient, you should not receive a bill for the visit beyond any copayment.
• If a practice will not accept Medicaid for your care, you should be told before you are seen, and you decide whether to proceed as a private-pay patient.
• A practice should not switch you to private pay after the fact because a claim was denied.

When private pay is allowed

Medicaid enrollment does not require a practitioner to treat every Medicaid enrollee who asks. New York's manual says that if a private payment arrangement is made, the enrollee should be told in advance of the practitioner's choice not to accept Medicaid reimbursement, and that the Medicaid program cannot be billed for services provided under that arrangement. It suggests the provider keep the patient's signed consent to be treated as private pay in the record.

Private pay is a legitimate choice. Some people want a particular clinician, longer appointments, or an approach their plan's network does not offer, and decide the cost is worth it. The point of the rule is that the decision is yours, made knowingly and before the visit.

For what a written estimate must include, see good faith estimates for self-pay psychiatry.

Medicaid Managed Care plans and their networks

Many New York Medicaid members receive care through a Medicaid Managed Care plan. For adults 21 and over enrolled in these plans, New York moved behavioral health services into Medicaid Managed Care, so both physical and behavioral health care are managed by the plan. Since July 1, 2019, the managed care behavioral health benefit has also covered eligible enrollees under 21. The state's consumer page says the adult changes do not apply to people who have both Medicaid and Medicare, people in nursing homes or Managed Long Term Care plans, or people receiving services from the Office for People With Developmental Disabilities.

The manual also covers providers who take Medicaid but are not in your plan's network. Such a provider may not bill you for services your Managed Care plan covers unless you agreed beforehand to be seen as a private patient, and the provider must tell you that the services may be available at no cost from a provider that participates in your plan.

Health and Recovery Plans (HARPs)

Adults with significant behavioral health needs may qualify for a Health and Recovery Plan, a Medicaid managed care plan that manages physical health, mental health and addiction services together. To join, a person must be 21 or older, eligible for Medicaid managed care, and meet the state's behavioral health high-risk criteria; eligible people receive a letter from the state or New York Medicaid Choice. HARP members must be offered care management through a state-designated Health Home.

When the network cannot provide the care you need

Federal managed care rules require the state to make sure that, if a plan's network is unable to provide a necessary covered service to a particular member, the plan covers that service out of network, adequately and in a timely way, for as long as the network cannot provide it. The plan must also make sure the member's cost is no greater than it would be in network. The same rule requires plans to provide a second opinion from a network provider, or arrange one outside the network, at no cost to the member.

If you cannot find an in-network psychiatrist who can treat your condition, ask your plan in writing for help finding one, and if it cannot, ask for an out-of-network authorization under this rule. Keep a record of each call. If the plan refuses, you can appeal; see how to appeal a denied mental health claim. If limits on mental health care seem stricter than limits on medical care, mental health parity rights explains what to look for.

A short script for calling your plan

Call the member services number on your plan card and ask, in this order:

1. "Can you give me a list of in-network psychiatrists and psychiatric nurse practitioners near me who are accepting new patients?"
2. "Do any of them treat my specific condition, and do any offer telehealth?"
3. "If none can see me, how do I request out-of-network care because the network cannot provide this service?"
4. "Is there a care manager or behavioral health coordinator who can help me find a provider?"
5. "Can you send me the answer in writing, or give me a reference number for this call?"

Write down the date, the name of the person you spoke with, and what they said. If you call several in-network offices and none can see you, that record supports a request for out-of-network authorization.

The prescription rule private-pay patients often miss

Seeing a psychiatrist privately does not stop you from using Medicaid at the pharmacy, but only if the prescriber is enrolled in New York Medicaid. The state's Medicaid pharmacy manual says licensed practitioners authorized to prescribe in New York must be enrolled in the Medicaid program to prescribe to New York Medicaid members. When a pharmacy is given a prescription from a licensed prescriber who is not enrolled, the manual says its only option is to obtain a new prescription from an enrolled provider.

The same manual notes that, under federal regulations, all ordering or referring physicians and other professionals must be enrolled in the Medicaid program. That can affect lab tests ordered by a private-pay clinician as well.

Before a first private-pay visit, ask the practice whether its prescribers are enrolled with New York Medicaid for prescribing. If they are not, plan how prescriptions will be handled, for example by paying for medication yourself, or by having an enrolled clinician write them. Do not stop or change a medication on your own because of a coverage problem; talk to your prescriber first. For other ways to reduce medication costs, see lowering prescription costs for psychiatric medications.

Emergencies are different

New York's manual states that, other than legally established copayments, a Medicaid enrollee should never be required to pay out of pocket for medically necessary inpatient services or medically necessary services in a hospital emergency room, regardless of whether the individual practitioner treating the enrollee in the facility is enrolled in Medicaid. A private-pay arrangement with an outpatient psychiatrist does not change that.

If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room. For other urgent options in the city, see psychiatric emergency or urgent need in New York City.

Comparing your routes to care

For most people on Medicaid, starting in network is the sensible first step, because the cost difference is large. Private pay can make sense for a defined purpose, such as a second opinion or a specific assessment, especially if your plan has not been able to provide it. The questions in is out-of-pocket integrative psychiatry worth it can help you decide, and levels of mental health care explained covers programs your plan may cover when outpatient care is not enough.

If you have Medicaid and Medicare

People with both Medicaid and Medicare follow different rules: the state's consumer page says the adult behavioral health managed care changes described above do not apply to them, and HARP enrollment is for people eligible for Medicaid managed care. Medicare's own rules on participating, non-participating and opted-out clinicians also come into play. Read Medicare and out-of-network psychiatrists and ask both programs before agreeing to pay privately.

How Dr. Lewis's practice handles Medicaid

Dr. Lewis is an out-of-network provider with all insurance plans, including Medicare, Medicaid and Medicaid Managed Care plans, as are all of the practice's practitioners, and payment is due at the time of service. The practice offers a Good Faith Estimate of expected costs before starting care, and lab and supplement costs are separate from visit fees. On the free discovery call you can ask about care options, scheduling and insurance. If you need care that is in network with your plan, ask the team on the discovery call about options. Fees are on the insurance and payment page, and the practice's New York services page describes where it sees patients. The full cost and insurance series is in the Choosing Psychiatric Care guide.

Frequently asked questions

Can I get reimbursed by Medicaid if I pay a psychiatrist privately?

No. New York's Medicaid manual says the Medicaid program cannot be billed for services provided under a private payment arrangement, so there is no reimbursement afterward.

A practice billed me after my Medicaid claim was denied. Is that allowed?

If the provider accepted you as a Medicaid patient, New York's rules generally bar charging you when a claim is denied for reasons other than ineligibility on the date of service. Ask the provider for the denial reason and contact your plan or New York Medicaid if the bill stands.

My plan has no psychiatrist available. What can I ask for?

Ask your Medicaid Managed Care plan, in writing, to find an in-network psychiatrist. If its network cannot provide the service, federal rules require the plan to cover it out of network at no greater cost to you than in network.

Can a private-pay psychiatrist send prescriptions that Medicaid will cover?

Only if the prescriber is enrolled in New York Medicaid. A pharmacy cannot bill Medicaid for a prescription from a licensed prescriber who is not enrolled; it has to obtain a new prescription from an enrolled provider.

Do I have to sign anything to be seen as a private-pay patient?

New York's manual requires a mutual, voluntary agreement made before the service and suggests the provider keep your signed consent. Ask for the agreement in writing and keep a copy.

Are therapists in my Medicaid plan also covered?

Behavioral health services, including therapy, are generally managed by your Medicaid Managed Care plan, for adults and, since July 2019, for enrollees under 21. Ask the plan for its list of in-network therapists and psychiatrists.

Sources

1. 42 CFR 447.15, Acceptance of State payment as payment in full. Electronic Code of Federal Regulations, 2026. ecfr.gov
2. Information for All Providers: General Policy (Version 2022-2). New York State Department of Health, eMedNY, 2022. emedny.org
3. NYRx Medicaid Pharmacy Program: Pharmacy Manual Policy Guidelines (2026-3). New York State Department of Health, 2026. emedny.org
4. 42 CFR 438.206, Availability of services. Electronic Code of Federal Regulations, 2026. ecfr.gov
5. Health and Recovery Plans (HARPs). New York State Office of Mental Health, 2026. omh.ny.gov
6. Information for Consumers/Medicaid Recipients: Changes to Medicaid Managed Care and Behavioral Health. New York State Department of Health, 2026. health.ny.gov
7. Behavioral Health Transition to Medicaid Managed Care for Children Under 21 Years of Age (Medicaid Update, May 2019). New York State Department of Health, 2019. health.ny.gov

Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.