New York's Network Adequacy Rule: Getting Out-of-Network Mental Health Care at In-Network Cost

If your New York health plan cannot connect you with an appropriate in-network mental health clinician, state law can require it to let you see an out-of-network clinician while you pay only what you would have paid in network. Two separate rules do this. Insurance Law 4804 (and Public Health Law 4403 for HMOs) requires a referral to an out-of-network provider when a managed care plan determines it has no in-network provider with the training and experience to meet your particular needs, "at no additional cost" beyond in-network cost-sharing. And since 1 July 2025, plans must offer an initial outpatient behavioral health appointment within 10 business days; when they cannot, they must approve an out-of-network provider who can, at the in-network copay, coinsurance and deductible.

Both protections apply only to coverage regulated by New York. They do not apply to self-funded employer plans governed by the federal ERISA law, which many large employers use. This article is general information, not tax or legal advice; your plan documents and your plan's written decisions control your situation.

Two New York rules, side by side

People often call both of these "network adequacy" rights, but they work differently. One is about expertise, the other about timeliness. Knowing which one fits your situation tells you what to ask for and what proof matters.

First, check whether New York law covers your plan

This is the step most people skip, and it decides everything else. The 2025 behavioral health access rules apply to individual and group policies subject to New York law, including Marketplace plans, Medicaid Managed Care, Child Health Plus and the Essential Plan. The state says they do not apply to self-funded ERISA plans. The Department of Financial Services (DFS) also notes that if your employer's group policy was issued in another state, that state's rules apply instead.

To find out what you have:

• Ask your employer's benefits or HR office one direct question: is our health plan fully insured or self-funded? An insurance company's name on your card does not settle it, because insurers also administer self-funded plans.
• Read the first pages of your certificate of coverage or summary plan description. A New York insured policy will usually describe New York appeal and external appeal rights.
• If you buy your own plan through NY State of Health, or you have Medicaid Managed Care, Child Health Plus or the Essential Plan, the state rules apply to you.

If your plan is self-funded, you still have federal rights: the federal parity law and federal claims and appeal rules. Those are covered in your rights under mental health parity law and how to appeal a denied mental health claim.

Route 1: the access complaint when you cannot get a timely appointment

This route is the faster and more concrete of the two, because the standard is a number of days rather than a judgment about expertise. New York's consumer guidance describes it in a few steps.

1. Try to book with in-network providers first, using the plan's directory and its behavioral health help line. Plans must have dedicated staff to help you find an in-network provider, with a direct phone number posted on the plan's website.
2. Keep a log: each provider you called, the date, and the earliest appointment offered (or "not taking new patients").
3. Contact the plan by phone, online or as your policy describes, say you cannot get an appointment within the required time, and say you want to file an "access complaint."
4. The plan then has 3 business days to give you the name and contact information of an in-network provider who can see you in time. For an access complaint, the plan must verify that the provider actually has the appointment before it gives you the contact details.
5. If no in-network provider is available, the plan must approve an out-of-network provider who can meet the wait time, and you pay only the in-network copay, coinsurance and deductible.

Two details matter. First, an in-network telehealth provider who can treat your condition in time resolves the complaint unless you asked for an in-person appointment. If you want to be seen in person, say so when you file. Second, the out-of-network provider the plan approves must be able to treat your condition, meet the wait time, be a reasonable distance away for in-person care, and charge rates that DFS describes as "not excessive or unreasonable." You can suggest a provider, but the plan applies those criteria.

The rule applies to policies issued or renewed on or after 1 July 2025. If your plan renewed before that date and has not renewed since, ask the plan when the new standards begin for you.

Route 2: a network-gap referral for expertise your plan lacks

The older protection in Insurance Law 4804(a) is about fit, not speed. If an insurer offering a managed care product determines it has no participating provider "with appropriate training and experience" to meet your particular needs, it must refer you to an appropriate out-of-network provider. The referral follows a treatment plan the insurer approves in consultation with your primary care provider, the out-of-network provider, and you or your designee, and the care is covered at no additional cost beyond what you would pay in network. Public Health Law 4403 sets the same rule for HMOs.

What counts as "appropriate training and experience" is a clinical question decided case by case. Examples of the kind of need a request might describe include a child or teen who needs a child and adolescent psychiatrist when the plan's listed psychiatrists treat adults only, a pregnant or postpartum patient who needs medication decisions from a clinician experienced in that period, or a treatment that only certain specialists provide. A request is stronger when it names the specific need and explains why the in-network options the plan suggested do not meet it.

Building the request

• A letter from your treating or referring physician describing your diagnosis, the specific expertise needed and why it matters clinically.
• The names of in-network providers you contacted or reviewed and why each does not fit (for example, does not treat your age group or condition).
• The out-of-network clinician you are asking for and their relevant training.
• A request that the plan put its decision in writing.

The law also provides for standing referrals to a specialist when you need ongoing specialty care, and the treatment plan can limit the number of visits or the time period. Ask how many visits an approval covers and how renewal works before the first visit, so you are not caught by an expired authorization.

If your plan says no

A refusal to refer you out of network because the plan believes it has a suitable in-network provider is called an "out-of-network referral denial" in New York law. You can appeal it.

• Internal appeal. Submit a written statement from a qualified physician that the in-network providers the plan recommended lack the training and experience to meet your particular needs, and that recommends an out-of-network provider who has them.
• External appeal. If the denial is upheld, you can ask DFS for an external appeal. The attending physician, who must be licensed and board certified or board eligible in the relevant specialty, must certify that the recommended in-network providers "do not have the appropriate training and experience" and recommend an out-of-network provider who does.
• Deadline. DFS says patients must file an external appeal within 4 months of the final adverse determination; providers have 60 days. Standard decisions come within 30 days, and expedited decisions within 72 hours. A plan may charge a small filing fee, which is waived for Medicaid and Child Health Plus enrollees and in cases of hardship. The DFS external appeal page has the application and the physician attestation forms.

For problems with the wait-time rule, start with the plan. If it does not comply, people with state-regulated commercial coverage can complain to DFS, and Medicaid, Essential Plan and Child Health Plus members can complain to the State Department of Health. The Community Health Access to Addiction & Mental Healthcare Project (CHAMP, 1-888-614-5400) helps with complaints and denial appeals. The step-by-step consumer version is on the state's Your Rights: Access to Behavioral Health Services page.

When your clinician leaves the network, or you are new to the plan

Section 4804 also protects continuity of care. If your provider leaves the plan's network, you can generally continue an ongoing course of treatment with that provider for a transitional period of 90 days from the later of the plan's notice of the departure or the departure date, or, if you are pregnant, through the pregnancy and directly related postpartum care. If you are newly enrolled and your current provider is out of network, a separate transitional period applies; the statute shows it as 60 days until 1 January 2027 and 90 days from that date. These periods come with conditions set out in the statute, so ask the plan in writing how they apply to you.

A paper trail checklist

Plans decide these requests on the record. Building that record as you go is the single most useful thing you can do.

Limits worth knowing before you rely on these rules

• Approval comes first. Both protections run through the plan's approval. If you see an out-of-network clinician before the plan approves the referral, the visit will usually be processed under your ordinary out-of-network benefits, if you have any.
• The plan chooses among qualifying options. If an in-network telehealth provider can see you in time and you did not ask for in-person care, the plan can meet its duty that way.
• The out-of-network clinician must agree. An approved referral does not oblige a particular practice to accept the plan's payment terms. Ask the plan how the provider will be paid and ask the provider, in writing, whether you could owe anything beyond your in-network cost-sharing.
• Self-funded plans are outside these rules. If your employer self-funds, ask your plan whether it has its own exception process for network gaps, and use federal parity and appeal rights if care is denied.

If no state protection applies, your next step is to compare real costs between in-network and out-of-network care; comparing in-network and out-of-network psychiatry costs walks through that, and a call script for checking your out-of-network benefits covers what to ask the plan. Medicaid members have additional considerations covered in Medicaid and private-pay psychiatry in New York.

How Dr. Lewis's practice fits into this

Dr. Lewis and all of the practice's clinicians are out of network with all insurance plans, including Medicare and Medicaid, and payment is due at the time of service. The practice provides a superbill you can submit for possible out-of-network reimbursement, and for BCBS, Aetna or Cigna plans it can facilitate submitting the out-of-network claim for you. If you need care that is in network with your plan, ask the team on the discovery call about options. Insurance and payment details are on the insurance and payment page, and you can start with a free discovery call through the get started page. More guides on cost and coverage are in the Choosing Psychiatric Care guide.

Frequently asked questions

Does the 10-business-day rule apply to follow-up visits with a psychiatrist I already see?

The headline standards are for an initial outpatient visit (10 business days) and follow-up after a hospital or emergency room discharge (7 calendar days). The state's consumer guidance names only these two standards, so ask your plan which standard, if any, applies to a routine follow-up appointment.

Can I pick the out-of-network psychiatrist the plan approves?

You can propose one, and it helps to do so. Under the wait-time rule the plan must approve an out-of-network provider who can treat your condition, meet the wait time, is a reasonable distance away for in-person care and charges rates that are not excessive or unreasonable. The plan applies those criteria, so your choice is not guaranteed.

Will the plan pay for visits I had before it approved the referral?

Do not count on it. Both New York routes run through plan approval, and visits before approval are usually processed under your regular out-of-network benefits. Get the approval in writing first, with the number of visits and dates it covers.

My card shows a big insurer's name. Does that mean New York law applies?

Not necessarily. Large insurers also administer self-funded employer plans, which are governed by federal ERISA law rather than New York insurance law. Ask your benefits office whether the plan is fully insured or self-funded.

Does Medicaid Managed Care have the same wait-time protection?

Yes. New York applies the behavioral health wait-time standards to Medicaid Managed Care, Child Health Plus and the Essential Plan through a Department of Health rule, and complaints about those plans go to the Department of Health.

Who can help me if the plan is not responding?

The CHAMP program (Community Health Access to Addiction & Mental Healthcare Project) helps with behavioral health insurance complaints and appeals. People with state-regulated commercial coverage can also complain to the Department of Financial Services.

Sources

1. New York Insurance Law Section 4804: Access to specialty care. New York State Senate (Consolidated Laws), 2026. nysenate.gov
2. New York Public Health Law Section 4403: Health maintenance organizations; responsibilities. New York State Senate (Consolidated Laws), 2026. nysenate.gov
3. New York Insurance Law Section 4900: Definitions. New York State Senate (Consolidated Laws), 2026. nysenate.gov
4. New York Insurance Law Section 4904: Appeal of adverse determinations by utilization review agents. New York State Senate (Consolidated Laws), 2026. nysenate.gov
5. New York Insurance Law Section 4910: Right to external appeal. New York State Senate (Consolidated Laws), 2026. nysenate.gov
6. Governor Hochul Launches Public Awareness Campaign to Educate New Yorkers on Access to Behavioral Health Treatment. New York State Department of Financial Services, 2026. dfs.ny.gov
7. Your Rights: Access to Behavioral Health Services. New York State, 2026. ny.gov
8. Network Adequacy and Access Standards for Behavioral Health Services (11 NYCRR 38) FAQs. New York State Department of Financial Services, 2025. dfs.ny.gov
9. File an External Appeal. New York State Department of Financial Services, 2026. dfs.ny.gov
10. Health Insurance for Transgender New Yorkers. New York State Department of Financial Services, 2025. dfs.ny.gov

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