Mental Health and Substance Use Disorder Coverage

There are many protections and coverage requirements for mental health and substance use disorder services under comprehensive health insurance policies that are sold in New York.

Learn more via the Know Your Rights: Getting Treatment for Mental Health and Substance Use Disorders (PDF) factsheet. Translated versions of this factsheet can be accessed at the bottom of this page.

New York Protections Apply to the Following Health Insurance Coverage

New York mental health and substance use disorder protections and coverage requirements apply to individual and group health insurance policies that you or your employer buy in New York including:  

  • through the New York State of Health Marketplace.  
  • from a broker or an insurer in New York.  

If you have Medicaid, Child Health Plus, or Essential Plan coverage, New York protections apply, but there are different rules. Check with the New York State Department of Health (DOH) at (800) 541-2831 for Medicaid, (800) 206-8125 for Medicaid Managed Care and Child Health Plus, and (855) 355-5777 for Essential Plan coverage.

If you have Medicare, different rules apply. Check with Centers for Medicare & Medicaid Services (CMS) at (800) MEDICARE, the Medicare Rights Center at (800) 333-4114, or www.medicarerights.org.

If you don’t know what type of coverage you have, check your health insurance ID card or contact your insurer or employer.     

New York Protections Do Not Apply to the Following Coverage

New York mental health and substance use disorder protections and coverage requirements do not apply to:

  • Out-of-State Coverage.  If you or your employer buy a health insurance policy in another state, the rules of that other state will apply. For example, if your employer has offices in several states and buys a health insurance policy in a state other than New York, then New York protections and coverage requirements won’t apply even if the policy covers people in New York.
  • Self-Funded Group Coverage. This is coverage that an employer self-funds (which many large employers do), and an insurer may still process claims, but New York protections don’t apply.   

If you don’t know what type of coverage you have, check your health insurance ID card or contact your insurer or employer.

Mental Health and Substance Use Disorder Preventive Screenings

If you have a comprehensive health insurance policy that is not grandfathered,* the policy must cover preventive services without cost-sharing (deductible, copayment, or coinsurance) that are recommended by the United States Preventive Services Task Force (“USPSTF”) as A or B recommendations. This includes the following mental health and substance use disorder screenings that are usually offered by a primary care provider:

  • Adult Depression. Screening for depression and suicide risk in adults, including pregnant and postpartum persons.
  • Adolescent Depression. Screening for major depressive disorder in adolescents aged 12 to 18.  
  • Anxiety. Screening for anxiety disorders in children and adults aged 64 or younger, including pregnant and postpartum persons.
  • Drug Use. Screening for unhealthy drug use in adults aged 18 or older and offering services or a referral for diagnosis and treatment.
  • Alcohol Use. Screening for unhealthy alcohol use in adults aged 18 or older, including pregnant women and providing persons engaged in risky or hazardous drinking with brief behavioral counseling to reduce unhealthy alcohol use.  
  • School-aged Children Tobacco Use. Education or brief counseling for school-aged children to prevent tobacco use.  
  • Adult Tobacco Use. Screening all adults and pregnant persons for tobacco use, advising them to stop using tobacco, and providing behavioral interventions and medication.  
  • Intimate Partner Violence. Screening for intimate partner violence in women of reproductive age and providing or referring women who screen positive to ongoing support services.  

*Grandfathered policies are those that have been in effect since 2010 and have not significantly changed. Check your health insurance policy or contact your insurer to see if your policy is grandfathered.  

For additional information, please see the A and B recommendations on the USPSTF’s website.

Mental Health and Substance Use Disorder Services

Your health insurance policy must cover the diagnosis and medically necessary inpatient and outpatient treatment of a mental health condition or substance use disorder as follows:

Inpatient Services

  • Hospital. Inpatient mental health and substance use disorder services in a hospital.
  • Crisis Residence Facility – Mental Health. Inpatient sub-acute mental health services in a crisis residence facility licensed or operated by the NYS Office of Mental Health.
  • Facility – Substance Use Disorder. Inpatient substance use disorder detoxification and rehabilitation services in a facility, including a residential facility, licensed, certified, or otherwise authorized by the NYS Office of Addiction Services and Supports.

Outpatient Services

  • Provider Office – Mental Health. Outpatient mental health services in a health care provider’s office (psychiatrist, psychologist, mental health counselor, marriage and family therapist, psychoanalyst, nurse practitioner, and licensed clinical social worker).
  • Facility – Mental Health. Outpatient mental health services in a facility certified or operated by the NYS Office of Mental Health.  (However, some services, like assertive community treatment, critical time intervention services, and mobile crisis services, are not required to be covered yet.)
  • Facility – Substance Use Disorder. Substance use disorder services provided by a facility licensed, certified, or authorized by the NYS Office of Addiction Services and Supports.
  • Crisis Stabilization Center – Mental Health and Substance Use Disorder. Outpatient mental health and substance use disorder services in a crisis stabilization center licensed by the NYS Office of Mental Health.
  • School-based Mental Health Clinic. Outpatient mental health services in a school provided by a school-based mental health clinic licensed by the NYS Office of Mental Health, regardless of whether it is in-network.

Coverage (other than for school-based services) may be limited to providers and facilities listed in your health insurance policy that are in your insurer’s network (in-network provider).

Ask your provider if they offer telehealth services if you do not want an in-person appointment in your provider’s office.  

Your doctor may recommend treatment, but your insurer might not agree it is medically necessary. See below under Appealing Your Medical Necessity or Out-of-Network Provider Denial for a description of your rights if that happens.

Check your health insurance policy. Request a copy by calling the Member Services number on your health insurance ID card or asking your employer.

Provider Directory

You can find in-network providers by:  

  • Website. Checking the provider directory on your insurer’s website.
  • Provider Directory Copy. Requesting a copy of the provider directory from your insurer.
  • Contacting Insurer. Asking your insurer about a specific provider.

The provider directory will include information about:

  • Location. The provider’s location including city/town and zip code.
  • Services. Limits on the availability of services (for example, age limits or conditions treated by the provider).
  • Telehealth. If services are available by telehealth.
  • Language. Languages spoken by the provider.
  • Affiliations. The provider’s connection with participating facilities.  
  • Level of Care. Whether facilities offer inpatient, outpatient, partial hospitalization, and intensive outpatient programs.

Provider Directory Misinformation. If you receive services from a provider that is listed as in-network in your insurer’s provider directory but the provider is no longer in-network, or if your insurer told you (by email or in-writing) that the provider is in-network,  you are only responsible for your in-network copayment, coinsurance, and deductible.

Provider Directory Reporting. If you would like to report a problem with the provider directory, your insurer’s website must explain how to do that.    

Finding an In-Network Provider for Mental Health and Substance Use Disorder Services

If you need help finding an in-network provider for mental health and substance use disorder services:

  • Ask for Help. Your insurer is required to have staff available to help you find an in-network provider that can treat your mental health condition or substance use disorder.
  • Website. Your insurer must post the telephone number on its website of the department or unit that can help you find an in-network provider.
  • Information Request. You or your designee may also ask your insurer to give you a list of in-network mental health and substance use disorder providers that are available to treat your condition. Your insurer must give you this list within 3 business days of your request.

Appointment Wait Times for Outpatient Mental Health and Substance Use Disorder Services

Your insurer must have in-network mental health and substance use disorder providers that will offer you an outpatient appointment for mental health and substance use disorder services within the following timeframes beginning on and after July 1, 2025 (when you buy or renew a health insurance policy):

  • 10 business days – First appointment at an outpatient facility, clinic, or with a health care professional.
  • 7 calendar days – Any follow-up after being discharged from a hospital or emergency room.

These appointments may be provided by telehealth, unless you request an in-person appointment.

Filing an Access Complaint to Request A Referral to an Out-of-Network Provider for Mental Health and Substance Use Disorder Services

If you are unable to schedule an outpatient appointment with an in-network provider for mental health or substance use disorder services within the required appointment wait times, you may file an Access Complaint with your insurer by telephone or in writing.

  • How to File An Access Complaint. Check your insurer’s website for information about how to file an Access Complaint.
  • Timeframes. When you file an Access Complaint, your insurer will have 3 business days to give you the name of an in-network provider who:
    • can treat your mental health condition or substance use disorder;
    • can meet the appointment wait times; and
    • is located a reasonable distance from you (if you want an in-person appointment).
  • Out-of-Network Provider. If your insurer cannot locate an in-network provider, your insurer must approve a referral to an out-of-network provider as long as the provider:  
    • can treat your mental health condition or substance use disorder;  
    • can meet the required appointment wait times;  
    • is located a reasonable distance from you (if you want an in-person appointment); and  
    • does not charge excessive or unreasonable rates.  
  • Cost-Sharing. Your copayment, coinsurance, and deductible for the out-of-network provider will be the same as if you were seeing an in-network provider.
  • Resolution of Access Complaint. If you disagree with how your Access Complaint is resolved, you can appeal with your insurer, and you can file a complaint with DFS.  

Duration of Referral to an Out-of-Network Provider for Mental Health and Substance Use Disorder Services

  • Duration of Referral. When your insurer approves a referral to an out-of-network provider for outpatient mental health or substance use disorder services, the referral must remain in effect until:
    • the services are no longer medically necessary; or
    • your insurer locates a participating provider that:
      • can treat your mental health condition or substance use disorder;
      • can meet the required appointment wait times; and
      • is located a reasonable distance from you (if you want an in-person appointment), unless your insurer determines, in consultation with your provider, as appropriate, that such transition would be harmful to you.
  • Appealing Your Insurer’s Decision. If you or your designee disagrees with your insurer’s decision to transition your care to an in-network provider or your insurer’s medical necessity decision, you or your designee may request an expedited determination or appeal with your insurer. 

Types of Cost-Sharing

You may have to pay a deductible, copayment, or coinsurance when receiving mental health and substance use disorder treatment.

  • Deductible. A deductible is the dollar amount that you need to pay before services will be covered by your insurer. If your deductible is $1,000, your health insurance policy won’t pay anything (except for preventive care) until you’ve paid $1,000 for covered services.
  • Copayment or Coinsurance. You may also have a copayment (set dollar amount) or coinsurance (a percentage of the costs) that you will need to pay for treatment.
  • Annual or Lifetime Limits. Your insurer can’t apply annual limits or lifetime limits on mental health or substance use disorder treatment.

Check your health insurance policy because the deductibles, copayments, or coinsurance may be different depending on the services you are getting.

Cost-Sharing for Outpatient Substance Use Disorder Treatment

Your health insurance policy must have the following limits on cost-sharing for outpatient substance use disorder treatment.

  • Opioid Treatment Programs. If you are covered under an individual, small group, or large group health insurance policy, you will not have to pay a copayment or coinsurance for treatment at an in-network opioid treatment program.
  • Outpatient Substance Use Disorder Treatment. If you are covered under a large group health insurance policy (employer policies with more than 100 employees):
    • Your copayment or coinsurance for any outpatient substance use disorder treatment from an in-network provider may not be more than the copayment or coinsurance that you would pay for a primary care office visit.
    • If you receive outpatient substance use disorder treatment in an in-network facility that is licensed or certified by the NYS Office of Addiction Services and Supports, you will only have one copayment for all services provided in a single day by the facility.

Cost-Sharing for Outpatient Mental Health Services at a Facility

If you are covered under an individual, small group, or large group health insurance policy, your copayment or coinsurance for any outpatient mental health treatment from an in-network provider in a facility licensed, certified, or authorized by the NYS Office of Mental Health may not be more than the copayment or coinsurance that you would pay for a primary care office visit. 

Out-of-Network Services

  • PPO or POS Coverage. If your health insurance policy has an out-of-network benefit (usually called PPO or POS coverage), you can get care from out-of-network providers who aren’t in your insurer’s network. Your cost-sharing will usually be higher for out-of-network services, and you will have to pay the difference between what your insurer pays for the service (allowed amount) and the provider’s actual charge (unless your insurer approves a referral or request for you to receive treatment with an out-of-network provider at the in-network cost-sharing).
  • School-Based Mental Health Clinics. For services provided at an out-of-network school-based mental health clinic, you will only be responsible for your in-network copayment or coinsurance.

Prohibited Discrimination

  • Non-Discrimination. Your insurer can't discriminate against you because of your mental health condition or substance use disorder.
  • Coverage, Termination, and Premiums. Your insurer can't refuse to cover you, terminate your coverage, or charge you higher premiums because of your mental health condition or substance use disorder.
  • Similar Benefits. Your insurer must provide a similar level of benefits for your mental health condition and substance use disorder as provided for medical and surgical care.

Medical Necessity

Your insurer may deny services as not medically necessary (including experimental or investigational services) through its utilization review process. Insurers use clinical review criteria (medical guidelines), which may vary among insurers, to make these determinations.

Clinical Review Criteria

You have a right to ask your insurer for a copy of the clinical review criteria (medical guidelines) that your insurer used to make a medical necessity decision. For mental health and substance use disorder treatment, insurers are required to use State-approved tools to decide if care is medically necessary.

Clinical Peer Reviewer

A clinical peer reviewer is the health care professional who decides if a service is medically necessary. For determinations involving mental health or substance use disorder treatment, the clinical peer reviewer must specialize and have experience in mental health or substance use disorder treatment.

Out-of-Network Provider

You may ask for your care to be provided by an out-of-network provider because there is no in-network provider with the training and experience to meet your health care needs (referral-denial) or because your insurer can’t cover the treatment you requested in-network but will cover a similar treatment (service denial).

Off-Formulary Prescription Drugs

You may request coverage of a prescription drug that is not on your insurer’s list of covered drugs (formulary), including a prescription drug to treat a mental health condition or a substance use disorder, and your insurer must approve the off-formulary prescription drug, if medically necessary.

Preauthorization (Prior Approval)

Preauthorization or prior approval is when your insurer decides whether a health care service, treatment, or prescription drug is medically necessary before you can get it. Your insurer can’t require preauthorization for the following services if you go to an in-network provider:  

  • Inpatient mental health and substance use disorder treatment.  
  • Outpatient substance use disorder treatment in a facility licensed, certified, or otherwise authorized by the NYS Office of Addiction Services and Supports.
  • Prescription drugs for substance use disorder.

Medical Necessity Reviews for Inpatient Mental Health Services for Individuals under 18

  • Preauthorization. If you are under the age of 18, your insurer can’t require you or your provider to request preauthorization for mental health treatment in an in-network facility that is licensed or operated by the NYS Office of Mental Health.
  • Concurrent Review. After you are admitted, your insurer can’t review the services for medical necessity during the first 14 days if the facility notifies your insurer of both the admission and the treatment plan within two business days of admission, performs daily clinical review of your case, and consults with your insurer.
  • Retrospective Review. If your inpatient treatment is denied retrospectively (meaning after your treatment has ended), you will not have to pay any amount to the facility for the treatment other than the copayment, coinsurance, or deductible otherwise required under your policy.

Medical Necessity Reviews for Inpatient Mental Health Services for Individuals 18 and Older

  • Preauthorization. If you are 18 years of age or older, your insurer may not require you or your provider to request preauthorization for mental health treatment provided in an in-network facility that is licensed or operated by the NYS Office of Mental Health.
  • Concurrent Review. After you are admitted, your insurer can’t review the services for medical necessity during the first 30 days if the facility notifies your insurer of the admission and the treatment plan within two business days of admission, performs daily clinical review of your case, and consults with your insurer. However, your insurer may perform concurrent review during the first 30 days if you meet clinical criteria designated by the NYS Office of Mental Health  or if you are admitted to a facility that has been designated by the NYS Office of Mental Health for concurrent review.  
  • Retrospective Review. If your inpatient treatment is denied retrospectively (meaning after your treatment has ended), you will not have to pay any amount to the facility for the treatment other than the copayment, coinsurance, or deductible otherwise required under your policy.

Medical Necessity Reviews for Inpatient Substance Use Disorder Services

  • Preauthorization. Your insurer can’t require you or your provider to request preauthorization for substance use disorder treatment in an in-network facility that is licensed, certified, or otherwise authorized by the NYS Office of Addiction Services and Supports.
  • Concurrent Review. After you are admitted, your insurer can’t review the services for medical necessity during the first 28 days if the facility notifies your insurer of the admission and treatment plan within two business days of admission.
  • Retrospective Review. If your inpatient treatment is denied retrospectively (meaning after your treatment has ended), you will not have to pay any amount for the treatment other than the copayment, coinsurance, or deductible otherwise required under your policy.

Medical Necessity Reviews for Outpatient Treatment of Substance Use Disorder

  • Preauthorization. Your insurer can’t require you or your provider to request preauthorization for substance use disorder treatment provided by an in-network facility that is licensed, certified, or otherwise authorized by the NYS Office of Addiction Services and Supports.
  • Concurrent Review. Once you begin outpatient treatment, your insurer can’t review the services for medical necessity during the first four weeks (not more than 28 visits) if the facility notifies your insurer of the start of treatment and the treatment plan within two business days.
  • Retrospective Review. If your outpatient treatment is denied retrospectively (meaning after your treatment has ended), you will not have to pay any amount for the treatment other than the copayment, coinsurance, or deductible otherwise required under your policy.

Medical Necessity for Prescription Drugs to Treat a Substance Use Disorder

Your insurer may not require you to get preauthorization for certain prescription drugs to treat a substance use disorder including, buprenorphine, methadone, injectable naltrexone, and opioid overdose reversal medication. Check your health insurance policy for more information.

Timeframes for Insurers to Make Medical Necessity Decisions and Referrals

(*These timeframes apply when medical necessity reviews are permitted.)

Appealing Medical Necessity or Out-of-Network Provider Denials

Your insurer must send you written notice if your treatment is denied. In urgent cases, your insurer must also contact you by telephone. If you don’t get a notice, you can file a complaint with DFS.

You have 180 days to appeal with your insurer.

Out-of-Network Provider Appeal (referral denial)

Your doctor must: (1) send a written statement to your insurer that the in-network providers recommended by your insurer do not have the training and experience to meet your health care needs; and (2) recommend an out-of-network provider with the training and experience to meet your health care needs who is able to provide the service.

Out-of-Network Provider Appeal (service denial)

Your doctor must: (1) send a written statement to your insurer that the out-of-network service is materially different from the health service the insurer approved; and (2) provide two documents of medical evidence that: (i) the out-of-network service is likely to be more clinically beneficial to you than the in-network service your insurer recommended; and (ii) the risk of the requested health service would not be increased over the in-network health service.

Timeframes for Insurers’ Appeal Decisions

Timeframes Formulary Exceptions for Prescription Drugs

  • Standard. 72 hours for insurer decision.
  • Expedited. 24 hours for insurer decision when your health, life, or ability to regain maximum function is in danger, or if you are currently being treated with a non-formulary prescription drug.

External Appeals

  • Right to External Appeal. If your insurer makes a determination (usually on appeal) that your treatment is not medically necessary (including an experimental or investigational treatment, an out-of-network service, an out-of-network referral, or a non-formulary prescription drug), you have a right to an external appeal with medical experts that are independent from your insurer.
  • Timeframe to Request External Appeal. You must send your external appeal request to DFS four months from the date of:
    • The final adverse determination from the first level of appeal with your insurer;
    • Notice that your insurer said you didn’t need to go through the internal appeal process; or
    • The first denial of your formulary exception request.
  • Second-Level Internal Appeal. If your insurer offers a second-level internal appeal, you do not have to file one, but if you do, you must still send an external appeal to DFS within four months of the first appeal decision.

Timeframe for the External Appeal Agent to Make a Determination

  • Standard: 30 days (or 72 hours for a formulary exception).
  • Expedited: 72 hours (or 24 hours for a formulary exception), even if all your medical information has not yet been submitted to the external appeal agent.

File an External Appeal

Learn how to file an External Appeal. There may be a $25 fee. Your fees won’t be more than $75 in a year if you request more than one external appeal. There is no fee if you are covered under Medicaid, Child Health Plus, Essential Plan, or if the fee will pose a hardship. The fee will be returned to you if the external appeal agent overturns the denial. You can also request help from Community Health Advocates, NY State’s insurance consumer advocacy group, at (888) 614-5400.

Learn how to file an External Appeal. There may be a $25 fee. Your fees won’t be more than $75 in a year if you request more than one external appeal. There is no fee if you are covered under Medicaid, Child Health Plus, Essential Plan, or if the fee will pose a hardship. The fee will be returned to you if the external appeal agent overturns the denial. You can also request help from Community Health Advocates, NY State’s insurance consumer advocacy group, at (888) 614-5400.

Surprise Medical Bills

  • Surprise Bill Protections. Surprise bills can happen when you receive services at an in-network facility from an out-network provider, when you are referred for services, or when you receive emergency services at a hospital.  You are protected from a surprise bill, and you are only responsible for your in-network copayment, coinsurance, or deductible. Learn more about how to dispute a surprise medical bill.
  • Hospital or Surgical Center Surprise Bill. A surprise bill happens when you receive services from an out-of-network provider at an in-network hospital or surgical center and:
    • an in-network provider was not available;
    • you did not know the provider was out-of-network; or
    • an unexpected medical situation happened when your health care services were provided.

It is not a surprise bill if you chose to receive services from an out-of-network provider instead of from an available in-network provider of if you sign a paper saying that you knew the services would be out-of-network.

  • Referral Surprise Bill. A surprise bill happens when your in-network doctor refers you to an out-of-network provider and you did not sign a paper saying that you knew the services would be out-of-network and would result in costs not covered by your insurer if:
    • during a visit with your in-network doctor, an out-of-network provider treats you;
    • your in-network doctor takes a specimen from you in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; or
    • for any other health care services when referrals are required by your insurer.
  • Emergency Services Surprise Bill. A surprise bill for emergency services happens when you receive emergency services at an out-of-network hospital or when you receive emergency services at an in-network hospital from an out-of-network provider.

Explanation of Benefits

Your insurer is required to send you an “explanation of benefits” form when it does not pay your claim in full. The explanation of benefits must include the following information.

  • Provider name.
  • Date of service and description of service.
  • Provider’s charge.
  • Amount your insurer will pay after deductible, copayments, or coinsurance.
  • Explanation of any denial or reason for not paying the full amount.
  • Insurer’s telephone number and information on how to appeal any denial of benefits. 

File a Complaint

You can file a complaint with DFS, The Department of Health, or with an independent ombudsman program depending on the type of coverage you have.

If you are covered by an insurer or HMO file a complaint with DFS. DFS will investigate your complaint. DFS may share a copy of your complaint with your insurer or refer it to another state agency, if necessary. Call DFS at (800) 342-3736 if you have any questions.

If you have Medicaid, Essential Plan, or Child Health Plus coverage file a complaint with the Department of Health at (800) 541-2831 for Medicaid, (800) 206-8125 for Medicaid Managed Care, (800) 698-4543 or locally at (518) 473-0566 for Child Health Plus, and (855) 355-5777 for Essential Plan coverage.  

If you are covered by an insurer or HMO or you have Medicaid, Essential Plan, or Child Health Plus you may also ask for help from New York’s independent Behavioral Health Ombudsman if you have questions, a complaint, or want to file an appeal for denied treatment with your insurer or HMO. The Community Health Access to Addiction & Mental Healthcare Project (CHAMP) helpline can be reached by calling (888) 614-5400 Monday-Friday, 9:00 AM-4:00 PM or by sending an email to: [email protected].

Outside Links and Resources

New York State Office of Addiction Services and Supports

New York State Office of Mental Health

New York State Department of Health

Mental Health and Substance Use Disorder Laws and Regulations

The following provides additional information about the laws and regulations governing Mental Health and Substance Use Disorder coverage.

Factsheets in Other Languages

Know Your Rights: Getting Treatment for Mental Health and Substance Use Disorders Factsheets