A lot of people assume that going out-of-network means something went wrong along the way, that a client couldn't find anyone else and settled for a more complicated path. For a meaningful number of Empire Plan members in Manhattan, the opposite is true. Choosing an out-of-network therapist is often the most deliberate decision in the entire search, made by clients who know exactly what they are looking for and are willing to pursue it directly.
What out-of-network means under The Empire Plan
An out-of-network provider is a licensed clinician who does not hold a contract with Carelon Behavioral Health, The Empire Plan's mental health administrator. You may recognize Carelon under earlier names, Value Options or Beacon Health Options, depending on how long you have been enrolled.
Working with an out-of-network therapist means the plan reimburses you directly for a portion of the cost, rather than the therapist billing the plan on your behalf. It is a genuine, plan-supported benefit, not a workaround or an exception. The Empire Plan builds out-of-network reimbursement into the design of the coverage specifically because it recognizes that the right clinical fit does not always live inside a contracted network.
Why members choose it on purpose
The most common reason is specialization. Therapists with deep experience in a particular clinical focus, whether that is trauma, a specific life transition, or a particular therapeutic approach like EMDR, often choose not to join insurance panels at all, so the clinician best suited to a client's actual situation is frequently found outside the network rather than inside it.
Continuity matters too. Clients who already have a strong working relationship with a therapist, and whose plan or employer changes over time, often stay with that clinician out-of-network rather than start over with someone new simply because a network changed.
Clinical autonomy plays a role as well. Therapists working outside insurance panels are not bound by network documentation requirements that can shape session frequency or treatment length around administrative criteria rather than clinical judgment alone. For clients whose needs do not fit neatly into a standardized framework, this flexibility is often the entire point.
How reimbursement works, in practical terms
Every out-of-network claim starts with documentation that includes your diagnosis code, procedure code, session date, and your provider's credentials. That documentation is submitted to The Empire Plan, typically through an online member portal, and reimbursement is calculated against the plan's allowed amount for the service, applied after any out-of-network deductible for the year has been met.
None of this requires you to become an expert in insurance billing. A quick call to Carelon before you begin gives you a clear, specific picture of your deductible status and reimbursement rate, so you know what to expect from the outset rather than piecing it together after the fact.
Making the most of your out-of-network benefit
A few habits make the process smoother from the start. Confirm with a prospective therapist how they document sessions for insurance purposes, since practices vary in how organized this process is on their end. Keep your own copy of anything submitted, along with the explanation of benefits that comes back. And treat the first call to Carelon as a planning tool rather than a hurdle. Knowing your numbers up front turns reimbursement into something predictable rather than something you find out about after the fact.
Bringing it together
Choosing an out-of-network therapist under The Empire Plan is not a compromise. For many Manhattan members, it is the clearest path to the clinician who actually fits what they need, backed by a real benefit the plan was designed to offer. Understanding how that benefit works turns it from an unfamiliar process into a straightforward one.
Humantold is an out-of-network practice in Midtown Manhattan, and that is a deliberate choice on our part as well. Operating outside insurance panels gives our clinicians the room to bring genuine clinical judgment to every case, rather than shaping care around network requirements. Our team is glad to help Empire Plan members understand their specific out-of-network benefits before starting, so the decision to work with us is an informed one from day one. Reach out, and we will help you understand what your benefit looks like.
Frequently asked questions
Is out-of-network therapy actually covered by The Empire Plan?
Yes. Out-of-network reimbursement is a built-in part of the plan's mental health benefit, administered through Carelon Behavioral Health.
Why would someone choose an out-of-network therapist instead of an in-network one?
Common reasons include finding a clinician with a specific specialty or approach, continuing with a therapist they already trust, and wanting a clinician whose care is shaped by clinical judgment rather than network requirements.
How does reimbursement work for out-of-network therapy under The Empire Plan?
You submit documentation of your sessions, including diagnosis and procedure codes, to The Empire Plan, and the plan reimburses a percentage of the allowed amount once any applicable deductible is met.
Do I need to do anything special to use my out-of-network benefit?
Not really. Confirming your specific deductible and reimbursement rate with Carelon before starting, and asking your therapist how they document sessions, are the two steps that make the process smoother.
Does Humantold help clients understand their out-of-network benefits? Yes. Our team is glad to help Empire Plan members understand what their specific out-of-network benefit provides before they begin treatment.