Why In-Network Mental Health Care Is So Hard to Find

Mental health coverage in the U.S. has expanded over the past decade, but real-world access hasn't kept up. Even among plans rated as the best health insurance, MoneyGeek's analysis of federal and industry data found that Americans are 3.5 times more likely to use out-of-network providers for mental health care than for other medical services, per RTI International. Nearly 137 million people, about 40% of the U.S. population, live in federally designated mental health shortage areas where providers can't meet demand, per the Health Resources and Services Administration (HRSA).

One of the biggest causes of this gap is financial. Medical and surgical clinicians are reimbursed 22% more than behavioral health providers on average, RTI International found. At the highest-cost tier, the gap widens to 70%. These lower rates push therapists, psychiatrists and psychologists away from insurance panels and into private-pay practice. For patients, the result is longer wait times, higher bills and, in too many cases, no treatment at all.

Americans use out-of-network providers for behavioral health care far more often than for medical or surgical services. RTI International's study of 22.8 million commercially insured people (2019 to 2021) found that behavioral health office visits were 3.5 times more likely to be out-of-network compared with medical and surgical visits, and the gap grows wider for specialized care.

RTI International's data shows psychiatrist visits were 8.9 times more likely to be out-of-network than a comparable medical appointment. For psychologist visits, the multiplier was 10.6 times. And for sub-acute behavioral inpatient care (residential treatment), patients were 19.9 times more likely to leave their network. Acute substance use disorder (SUD) inpatient admissions were 12.4 times more likely to be out-of-network.

The difference between behavioral health and medical/surgical out-of-network rates varies widely by service type, with residential and inpatient substance use treatment showing the largest disparities.

NAIC data shows out-of-network use is rare across health care overall, at just 6.8% of all claims. But RTI found behavioral health office visits were 3.5 times more likely to go out-of-network than comparable medical or surgical visits. Milliman's 2019 report showed this problem has been worsening: between 2013 and 2017, behavioral health providers went from being 2.8 times more likely to be out-of-network to 5.2 times more likely, an 85% increase in four years.

State-level data from Milliman tells an even sharper story. In Alaska, 64% of behavioral health claims were out-of-network compared with 22% for primary care. New Jersey's gap was 41% versus 4%. These gaps show a mental health system operating on a different economic model than the rest of health care.

Lower insurance reimbursement is one of the primary reasons therapists and psychiatrists leave networks. RTI International's analysis compared what insurers pay behavioral health clinicians versus medical and surgical clinicians for equivalent office visits. On average, medical and surgical providers are reimbursed 22% more. At the 75th percentile of claims, the gap is 48%. At the 95th percentile, it's 70%.

The APA's 2025 Practitioner Pulse Survey quantifies the downstream effect of those gaps: 38% of psychologists don't accept any form of insurance. Among those who opt out, 82% cite insufficient reimbursement as the top reason, followed by administrative burdens like preauthorization requirements (62%) and payment delays (52%). When providers won't join networks, patients either pay full price or skip care.

Medicaid rates are even lower. Health Affairs found that Medicaid pays psychiatrists at 81% of Medicare rates on average, with extreme state variation. Pennsylvania pays psychiatrists as low as 46% of Medicare rates. Nebraska pays 234%. That fivefold difference across states shapes where psychiatrists choose to practice and which patients they'll see.

Psychiatrist participation in Medicaid is just 35%, compared with 73% of primary care physicians, per data published in Psychiatric Services. And psychiatrists account for 42% of all Medicare opt-outs despite being a small fraction of total physicians. So the providers most needed for mental health care are the ones most likely to reject government insurance programs.

Out-of-network therapy can cost up to 174% more depending on location, per FAIR Health claims data. A 60-minute therapy session in Houston costs $129 in-network versus $353 out-of-network. In New York, the same session runs $185 in-network and $352 out-of-network, a 90% jump. Markets vary widely: in Jackson, Mississippi, the difference is only 8% ($191 versus $207).

Nationally, the average out-of-network therapy session costs about $149, compared with $84 in-network, per FAIR Health cost estimates. In-network copays usually run $20 to $58. Without any insurance, a session can cost $90 to $300 or more, depending on the provider's credentials and location. Licensed professional counselors, licensed marriage and family therapists and licensed clinical social workers charge $90 to $160 per session, while doctoral-level psychologists charge $150 to $250.

These price gaps compound over time. A patient seeing a therapist weekly at FAIR Health's national average would pay about $7,748 per year out-of-network ($149 x 52 sessions) versus $4,368 in-network ($84 x 52), a difference of $3,380 a year. In Houston, where the out-of-network fee is $353 per session, that annual total reaches $18,356 for weekly therapy. That's a financial weight that falls hardest on people already dealing with a mental health crisis.

Rural and Southern states have the worst mental health provider shortages. HRSA designates Mental Health Professional Shortage Areas (HPSAs) across the country. As of March 2026, 6,959 HPSAs cover about 137 million Americans. Only 26.8% of the mental health care demand in these areas is being met. HRSA estimates that roughly 6,800 additional practitioners are needed to close the gap.

Rural areas are hit hardest. The American Association of Medical Colleges (AAMC) reports that 65% of rural (nonmetro) counties have zero psychiatrists, and 81% lack psychiatric nurse practitioners. About 47% of rural counties lack psychologists, nearly three times the rate of urban counties. More than 60% of rural Americans live in mental health HPSAs, and wait times run up to three times longer than in urban communities.

The shortage is worsening. A study published in ScienceDirect found that the share of U.S. counties with mental health HPSAs grew from 83.5% to 87.6% between 2010 and 2016. Metro counties with HPSAs jumped from 64.6% to 96.1% during the same period. Between December 2024 and 2025, the population living in mental health HPSAs grew from 122 million to 137 million, an increase of 15 million people in roughly one year.

Texas has 380 mental health HPSAs and needs 614 additional practitioners, with 246 of its 254 counties designated as shortage areas. California has 627 HPSAs affecting 11.5 million people. West Virginia meets only 5.7% of its mental health demand, the lowest rate in the nation. Delaware meets 6.1%, the second lowest. Arizona meets 15.1%, and North Carolina meets 12%.

MoneyGeek built a composite Mental Health Access Score for all 50 states and Washington, D.C., by combining three federal and industry datasets: overall mental health provider supply (America's Health Rankings, September 2025), psychiatrist availability (KFF/Becker's, January 2025) and the share of mental health demand being met in each state (HRSA, March 2026). Each component was normalized to a 0 to 100 scale and weighted to produce a single score where 100 represents the best access.

Vermont ranks first with a score of 71.5, followed by Massachusetts (69.6). Washington, D.C., ranks third with a score of 67.3. 

Vermont has 613 mental health providers per 100,000 residents, one of the highest psychiatrist-to-population ratios in the country and roughly half of its designated shortage-area demand met. Massachusetts leads in raw provider count at 813.9 per 100,000 but scores lower on HRSA's demand metric. Washington, D.C., has the nation's highest psychiatrist concentration at 69.4 per 100,000, but also has zero percent of its HPSA demand met because its entire population falls within a designated shortage area, pulling its composite score below the top two states.

At the bottom, West Virginia scores 10.5, driven by just 223 providers per 100,000, 14.5 psychiatrists per 100,000 and only 5.7% of its mental health demand met. Tennessee (13.9) and Arizona (15.2) round out the bottom three. Alabama has the fewest mental health providers per capita in the country and scores 18.7. Its HRSA demand-met figure of 28.4% is above the national average, which softens its overall ranking.

Vermont's score is nearly seven times West Virginia's. States in the top 10 are concentrated in New England and the Pacific Northwest, while the bottom 10 are mostly in the South and Mountain West. That geographic pattern tracks closely with Medicaid reimbursement rates, state-level parity enforcement and medical school density, all of which affect whether providers choose to practice in a given state.

Provider supply varies by more than fivefold across states, from 822 providers per 100,000 in Alaska to 162.9 in Alabama. The total U.S. behavioral health workforce was about 1.2 million providers as of 2020, based on a George Washington University analysis funded by SAMHSA, including psychiatrists, psychologists, counselors and social workers. But that supply is unevenly distributed: Massachusetts has 813.9 providers per 100,000 residents, while Alabama has just 162.9, the lowest in the country. Washington, D.C., has the highest psychiatrist concentration at 69.35 per 100,000, compared with 11.05 in Alabama. That translates to roughly one mental health provider for every 123 residents in Massachusetts and one for every 614 in Alabama, per America's Health Rankings. MoneyGeek's guide to the best states for mental health services covers the full range.

Substance abuse and mental health counselors (483,500 as of 2024) are projected to grow 17% by 2034. Marriage and family therapists (77,800) are projected to grow 13%. But the supply of psychiatrists (59,281 as of January 2025 per Becker's) and doctoral-level psychologists is flat or declining relative to demand. HRSA projects a shortage of 43,660 to 93,940 psychiatrists by 2037, plus roughly 88,000 mental health counselors and 114,000 addiction counselors.

Having insurance doesn't guarantee a provider has openings. The APA's 2024 Practitioner Pulse Survey found that 53% of psychologists had no openings for new patients. Among those with waitlists, 69% reported waits of up to three months, and 31% said waits were even longer. A separate analysis put the mean wait time for mental health services at 94.1 days. The median wait for in-person psychiatry was 67 days; for telepsychiatry, 43 days.

Provider directories compound the problem. A 2020 Health Affairs study found that among privately insured mental health patients who used a provider directory, 53% found inaccurate listings (wrong phone numbers, providers no longer at that location, or providers not accepting new patients). Patients who relied on inaccurate directories were twice as likely to end up with out-of-network care (40% versus 20%) and four times more likely to get a surprise out-of-network bill (16% versus 4%).

KFF's 2024 Employer Health Benefits Survey shows employers are aware of these gaps. Only 70% of firms believed their plans provided timely access to mental health care, compared with 92% for primary care and 89% for specialty care. Just 67% said they had enough behavioral health providers in their networks, versus 91% for primary care.

About 61.5 million American adults had a mental illness in the past year, and roughly half didn't get treatment. SAMHSA's 2024 National Survey on Drug Use and Health (NSDUH) found that 23.4% of American adults had any mental illness. About 5.6% (14.6 million) had a serious mental illness.

Among adults with any mental illness, 50.6% received treatment. One in four adults with mental illness reported unmet need for care.

Cost is the biggest barrier. NSDUH data shows 59.8% of adults who didn't get needed treatment cited cost as a reason. Another 40.7% said they couldn't find the provider they wanted. And 9.6% of privately insured adults with mental illness said their coverage didn't include mental health treatment, totaling about 3 million people, per 2022-2023 NSDUH combined data.

Young people are especially affected: 20.3% of adolescents ages 12 to 17 had a mental health condition in 2023, and 61% of those who sought care reported difficulty getting it, a 35% increase since 2018. MoneyGeek's ranking of the best states for youth mental health covers access by state.

Racial disparities in treatment are stark. KFF data from 2022 shows 28% of white adults received mental health treatment, compared with 16% of Black adults, 16% of Hispanic adults and 9% of Asian adults. LGBTQ+ communities also see gaps: the Trevor Project's 2024 survey found that 41% of LGBTQ+ young people who wanted mental health care couldn't get it.

Women were nearly twice as likely to receive treatment as men (29% versus 17%). Insured adults were more than twice as likely as uninsured adults to get care (25% versus 11%). Deloitte estimates that mental health inequities cost the U.S. economy $477.5 billion in 2024.

Mental health claims grew 83% between 2019 and 2023, per FAIR Health. Behavioral health utilization in 2023 was 40% higher than pre-COVID levels. RAND found that mental health spending per 10,000 beneficiaries per month rose 53.7%, with the average monthly spending rate increasing from about $2.3 million to more than $3.5 million between March 2020 and August 2022. Health Affairs data shows total national spending on mental health and substance use disorder treatment grew from $40.9 billion in 2000 to $139.6 billion in 2021.

Community health centers have absorbed much of this demand but meet only about 27% of mental health need and 6% of SUD need, per NACHC. Telehealth has helped more broadly, though it hasn't closed the gap. Mental health's share of telehealth visits is five times larger than other outpatient care types, per KFF. About 36% to 43% of outpatient mental health claims now involve telehealth, up from roughly 2% before the pandemic. Large employers have responded: 29% increased telehealth mental health access in 2024, and 48% added mental health counseling resources through employee assistance programs (EAPs) or vendors.

Parity laws set an important legal floor but haven't closed the access gap in practice. The Mental Health Parity and Addiction Equity Act (MHPAEA), signed in 2008, requires group health plans to cover mental health and substance use services at levels comparable to medical and surgical care. A strengthened final rule published September 9, 2024, added new requirements for insurers to conduct comparative analyses of nonquantitative treatment limitations (NQTLs) like prior authorization and network adequacy standards.

Enforcement, though, has been inconsistent. The Department of Labor issued more than 120 enforcement letters in the 2024 reporting period, with 55 insufficiency letters covering 40-plus NQTLs. Only 32 initial determination letters found violations, and just three led to final determinations of noncompliance. In fiscal year 2023, the Employee Benefits Security Administration found 31 violations across only 17 investigations.

Then enforcement slowed further. On May 15, 2025, the Department of Labor, HHS and Treasury announced they wouldn't enforce the 2024 final rule while litigation is pending. That means the strongest parity requirements on the books are currently paused. KFF's employer survey shows the practical result: only 30% of small firms and 46% of large firms described their mental health provider networks as "very broad," compared with 54% and 68% for medical networks overall.

MHPAEA establishes a legal floor for coverage, but the law doesn't directly address the reimbursement gap that keeps providers out of networks. Until payment rates for behavioral health care move closer to medical and surgical rates, the law's promise of equal coverage will keep running into the reality of unequal access.

The data adds up to a consistent picture: having mental health coverage on paper doesn't mean patients can access it. Providers are paid less, so fewer join insurance networks. Patients are pushed out-of-network, where a single therapy session can cost 90% to 174% more.

Shortage areas cover 40% of the country, and the workforce isn't growing fast enough to close the gap. MHPAEA requires equal coverage, but enforcement of its strongest provisions is currently paused.

For the 61.5 million American adults with a mental health condition, these overlapping barriers mean longer searches, higher costs and, for many, no care at all. Cost is the top reason people skip treatment (59.8%), followed by not finding the provider they wanted (40.7%). These aren't separate problems. They're connected: low reimbursement shrinks networks, which raises prices, which puts care out of reach.

MoneyGeek analyzed data from RTI International, NAIC, HRSA, FAIR Health, KFF, SAMHSA, the APA, the BLS, Health Affairs, Milliman and additional federal datasets. RTI data reflects Merative MarketScan Commercial Database claims for 22.8 million privately insured people across all 50 states from 2019 to 2021. HRSA data covers federally designated Mental Health Professional Shortage Areas as of March 2026. FAIR Health estimates are based on ZIP-level private insurance claims and are used for cost illustration. 

Workforce figures come from SAMHSA, BLS occupational projections (2024 to 2034) and APA Practitioner Pulse Surveys (2024 and 2025). Treatment gap and prevalence data come from SAMHSA's 2024 NSDUH. Milliman trend data covers employer-sponsored plan claims for 37 million employees and dependents from 2013 to 2017. 

All figures were cross-referenced across sources for consistency. Where data points reflect different time periods or methodologies, those differences are noted in context.