Whether you’re switching plans or renewing the one you have, a new plan year is the right time to find out if your out-of-network therapist can be covered at in-network rates.

By Access to Coverage

Open enrollment for 2027 marketplace health insurance begins November 1, and many employers hold their own enrollment around the same time. Over the next few weeks, families across our community will choose new plans, switch carriers, or simply let their current coverage renew. And for most plans, deductibles start over at zero on January 1.

For anyone in therapy, or anyone paying a therapist who doesn’t take insurance, this is a moment worth paying attention to. Many people assume that if their therapist is out of network, they’re stuck paying out of pocket, especially if their plan has no out-of-network benefits at all. That assumption costs families a great deal of money every year, and very often it isn’t the whole story.

The Problem Many Families Face

Many of the therapists our community trusts most don’t accept insurance. They understand our families, our culture, and our values, and once you’ve found the right person, starting over with someone new isn’t a realistic option.

Meanwhile, the insurance company’s directory may list plenty of in-network names. But when you start calling, the story often changes: some aren’t taking new patients, some never call back, some are hours away, and some don’t have the experience your situation calls for. A list of names is not the same as real access to care.

Finding the right fit matters just as much. People come to therapy with specific struggles, and many therapists specialize in or have advanced training in those exact areas. In medical care, you need a doctor who can adequately treat your condition, and federal and state mental health parity laws generally require plans to treat mental health care no more restrictively than medical care. Network adequacy rules generally apply to mental health providers as well.

So if your therapist specializes in what you’re dealing with, speaks your language, or can see you at the times you’re actually available, those are real reasons to stay with them, and they can be part of the case for coverage.

If you’re in therapy, have a therapist you trust, and are making good progress, you don’t have to stop seeing them. Before you assume you’re stuck paying out of pocket, find out whether your therapy can be covered through your insurance.

Gap Exceptions and Single Case Agreements

Health plans are generally expected, and in many cases required by state or federal rules, to give members reasonable access to care through their network. When the network can’t provide an appropriate, available provider, a member may be able to request a network gap exception or a single case agreement (SCA). The two sound alike, but they work differently.

A single case agreement is an arrangement between the insurance company and your therapist. The insurance negotiates a rate with the therapist, and the therapist agrees to accept it for your sessions for a set period of time. In practice, the therapist is treated like an in-network provider for you, and you pay your in-network copay, deductible, and coinsurance.

A network gap exception is approved for you, the member. The plan agrees to cover your out-of-network therapist at your in-network benefit level. You keep seeing your therapist the same way you do today: you pay them, get receipts, submit them to the insurance, and the reimbursement is typically sent directly to you. Your therapist usually doesn’t need to sign a contract or negotiate a rate with the insurance company.

Out-of-Network Benefits or Not, You May Still Qualify

This is the point most people miss. These requests generally turn on whether the plan’s network can actually meet your needs, not on whether your plan happens to include out-of-network benefits.

• If your plan has no out-of-network benefits (common with EPO and HMO plans), you may still qualify. An approved exception may be the only way the plan will cover your therapist at all.
• If your plan does have out-of-network benefits (common with PPO and POS plans), you may still benefit, often significantly.

Here’s why. When you submit your therapy bills yourself under out-of-network benefits, you typically:

• Get nothing back until you meet the out-of-network deductible, which is usually separate and often large.
• Are reimbursed only a percentage of the plan’s “allowed amount,” which is usually based on a lower rate and can be far below what your therapist actually charges.

With an approved gap exception or single case agreement, your therapy is treated as in-network instead. That typically means:

• Your sessions count toward your in-network deductible, which is usually much lower.
• Depending on the plan, reimbursement may be based on a higher approved rate.
• The plan pays its in-network share, which is usually higher than its out-of-network share.

For someone in weekly therapy, that difference adds up quickly over the course of a year. Keep in mind that with a gap exception, you may still be responsible for the difference between your therapist’s fee and the amount the plan approves.

Why Now Is the Time to Act

• For most plans, deductibles reset on January 1. Getting a request in early means sessions in the new year can count toward the right deductible from the start.
• New plan, new rules. If you’re switching plans, your new plan has its own network, and any arrangement with your old plan generally doesn’t carry over.
• Renewing? Check anyway. Plans change their networks and benefits from year to year. Even if you’re keeping the same coverage, it’s worth reviewing where you stand for 2027.
• Approvals take time. These requests usually require documentation and follow-up with the plan. Starting in November or December is far better than starting in March.

Who Should Reach Out

If you have private insurance, whether through an employer or a plan you bought yourself, or a plan from the marketplace (Get Covered New Jersey, NY State of Health, or HealthCare.gov), and you see a therapist who doesn’t take your insurance, it’s worth finding out whether your therapy could be covered at in-network rates.

Therapists in private practice who don’t participate with insurance can also share this with their clients. Clients may be able to keep coming without the full cost falling on them.

Key Open Enrollment Dates

• New Jersey (Get Covered New Jersey): November 1, 2026 – January 31, 2027. Enroll by December 31 for coverage starting January 1.
• New York (NY State of Health): November 1, 2026 – January 31, 2027.
• Other states (HealthCare.gov): November 1, 2026 – January 15, 2027. Enroll by December 15 for coverage starting January 1.
• Employer plans: Your employer sets its own window. Watch for emails from HR.

Dates can change; confirm with your state’s official marketplace or your employer.

How Access to Coverage Helps

Access to Coverage is an insurance advocacy service based in Lakewood, NJ, working with clients across the United States. We help clients request network gap exceptions and single case agreements, and we advocate for you through the appeals process when a plan says no, so families can keep seeing the therapists they already trust. We’ve helped hundreds of families with their therapy coverage over the years.

We push for gap exceptions whenever possible. They’re usually much easier on everyone: your therapist keeps their usual practice and fees, and you get reimbursed at in-network levels. Many private and commercial insurance plans allow this.

• We do the legwork. Paperwork, phone calls, and follow-up with the insurance company, so you can focus on your care.
• Secure and HIPAA-compliant. We use up-to-date technology, and your information is handled through secure, HIPAA-compliant systems.
• Simple, transparent pricing. No approval fee unless your insurance company issues a written approval. There is a $150 non-refundable application fee to open your case. No percentage of your reimbursement and no hidden fees. The approval fee covers the approved authorization period; renewals and optional billing services are priced separately.
• Appeals included at no extra charge. If a request is denied, we follow through with the appeals process for you, and in some cases we also pursue an independent external appeal. There is no additional fee for appeals.
• Optional billing services. Once you’re approved, clients or therapists who need help submitting bills for reimbursement can use our optional billing service. We provide administrative support with submitting claims and follow-up, so the process runs smoothly for both the client and the therapist.

We’re here to help people get covered, and we advocate as strongly as we can for every client. If you have private or commercial health insurance, whether through your job, a plan you bought yourself, or the marketplace, reach out with any questions. We’ll be glad to help you try to get the coverage you, your spouse, or your family members need. Now is the time to act.

Questions? Reach out anytime. We’re here to help. Call or text (732) 475-2111.

Have a question? Find out if your therapy can be covered.
Reach out with any questions. We’re here to help. Contact Access to Coverage to see if your therapy can be covered at in-network rates.

Call or text: (732) 475-2111
WhatsApp: Message us on WhatsApp
Email: [email protected] (Email us anytime. We respond quickly.)
Online: www.accesstocoverage.com

Disclaimer: This article is for general informational purposes only and is not legal, financial, tax, or medical advice. Reading it does not create a client relationship with Access to Coverage.

Access to Coverage is an administrative insurance advocacy service. It is not a law firm, does not provide legal representation, and is not a therapy, medical, or mental health provider. It is not an insurance company or broker and is not affiliated with, endorsed by, or acting on behalf of any insurance carrier, employer, or government marketplace.

Coverage, network rules, deductibles, reimbursement rates, and eligibility vary by plan, employer, and state. Whether a gap exception, single case agreement, or appeal is approved is decided solely by the insurance plan or the reviewing authority. Approval is not guaranteed, and past results do not predict future outcomes. Even with an approval, you may be responsible for deductibles, copays, coinsurance, and any amount above what the plan allows.

Fees: a $150 non-refundable application fee applies to each request. The flat approval fee is charged only if the insurance company issues a written approval. Renewals and optional billing services are priced separately. Full terms are provided in writing before any engagement.

Enrollment dates are based on publicly announced information as of October 2026 and may change; confirm with your employer or your state’s official marketplace. Your information is handled under applicable privacy laws, including HIPAA. Sponsored content.