Costs
Out-of-network rehab with NYSHIP in 2026
The Empire Plan does pay some out-of-network substance use care, but differently by setting. Non-network outpatient care is paid at 80% of an allowed amount after a $1,250 combined deductible; non-network inpatient stays cost you 10% of billed charges up to a $3,750 coinsurance maximum. Either way, certification is required and some charges can remain yours.
Published by the NYSHIP.rehab editorial resource · Updated
Why are there two different out-of-network formulas?
| Non-network inpatient | Non-network outpatient | |
|---|---|---|
| Basis | Billed charges | Allowed amount (275% of published Medicare rates) |
| Your share | 10% coinsurance on the facility stay | Deductible, then 20% of allowed amount, plus any amount above it |
| Deductible | Inpatient practitioner bills: deductible and coinsurance apply | Combined annual deductible applies first |
| Coinsurance maximum | Counts toward the combined annual coinsurance maximum | After the maximum, plan pays 100% of the allowed amount |
| Printed page | p. 11 | p. 12 |
What does "275% of Medicare" actually mean?
The guides define the allowed amount as being based on 275% of the published rates allowed by CMS for Medicare for the same or similar service in the geographic market (printed p. 12). It is a ceiling for what the plan recognizes — not a promise to reimburse 275% of a provider's bill.
A simplified outpatient example
Suppose (hypothetically) a non-network session is billed at $400 and the allowed amount is $250. After your deductible is met, the plan pays 80% of $250 = $200. Your coinsurance is $50, and the provider may bill the remaining $150 above the allowed amount, making your share $200. Real numbers vary by service and location.
The guides suggest contacting Carelon Behavioral Health customer service (official number 1-877-769-7447, press or say 3) to estimate non-network costs.
Does NYSHIP cover luxury rehab?
Not as a luxury. The Empire Plan covers treatment that is certified as medically necessary — the clinical care itself. A program marketed as "luxury" may deliver covered clinical services, but optional amenities such as private suites, spa-style services, gourmet dining or recreational excursions are not medical treatment, and you should not assume the plan pays for them.
The At A Glance guides don't list specific amenity exclusions, so the practical answer depends on how the facility bills and on your Certificate. "Luxury" branding does not tell you a program's network status either way. Verify the exact facility, the specific program or level of care, and each clinician who will bill you — and don't rely on a program saying it "takes Empire," because the Empire Plan and Empire BCBS (Anthem) are different coverage. If the stay is non-network, the guides describe 10% coinsurance on billed charges, and uncertified days or uncovered items may be your full cost.
Ask a luxury or private-pay program for
- An itemized estimate separating clinical services from optional amenity charges
- Their Empire Plan network status for this level of care
- Whether they will request preauthorization/certification from the MHSU Program before admission
- A balance-billing estimate: what they expect you to owe above plan payment
- Their policy if a continued-stay review is denied
Considering a private program near home? See NYSHIP addiction treatment on Long Island.
Does the $3,750 coinsurance maximum cap everything?
No. The combined annual coinsurance maximum ($3,750 enrollee, $3,750 spouse/partner, $3,750 all dependent children combined) counts specific expenses, such as non-network MHSU coinsurance (printed p. 3). It does not cap the deductible, amounts above the allowed amount, uncovered services or care denied as not medically necessary.
See all three thresholds side by side on the 2026 deductibles and maximums page.
How can you lower out-of-network risk?
- Ask the Clinical Referral Line for a network option first — and about network-level access if none exists nearby (prior authorization guide).
- Get certification in writing before admission.
- Request written estimates and keep explanation-of-benefits statements.
- Learn which emergency services may have federal No Surprises Act (opens in a new tab) protections.
Frequently asked questions
Does NYSHIP cover luxury rehab?
The plan covers certified, medically necessary treatment, not luxury amenities. Ask any program for an itemized estimate separating clinical care from optional charges, plus network status, preauthorization and a balance-billing estimate.
Does the Empire Plan pay out-of-network substance abuse treatment in 2026?
Yes, with conditions: non-network outpatient care is paid at 80% of the allowed amount after the combined deductible, and non-network inpatient stays carry 10% coinsurance on billed charges, when services are certified as medically necessary.
Is the allowed amount 275% of my bill?
No. It is based on 275% of published Medicare rates for the same or similar service in the area. If a provider bills more than that, the difference can be your responsibility.
Related guides
- CostsHow much does rehab cost with NYSHIP?Estimate your Empire Plan rehab cost in five steps: network copays, the non-network deductible, coinsurance and balance billing.
- CostsNYSHIP 2026 deductibles, copays and out-of-pocket limits2026 Empire Plan figures for PE and C-82: in-network out-of-pocket limits, the $1,250 combined deductible, $3,750 coinsurance maximum and MHSU copays.
- CoverageNYSHIP inpatient and residential rehab coverageHow Empire Plan inpatient and residential rehab coverage works: certification, network stays paid in full, non-network 10% of billed charges and what to ask.
- CoveragePrior authorization for NYSHIP rehab: who calls, and whenWhen Empire Plan substance use care needs certification, who requests it, what happens in emergencies and a call checklist for the MHSU Program.
- CoverageHow Empire Plan rehab coverage works in 2026How The Empire Plan's Mental Health and Substance Use Program covers rehab in 2026: who it applies to, network vs non-network rules, and what to confirm first.
Sources and source dates
- The Empire Plan At A Glance — Participating Employers (PE), January 2026 (opens in a new tab) — January 2026 (AAG-PE-1/26). Printed page(s) 2, 3, 11, 12. New York State Department of Civil Service.
- The Empire Plan At A Glance — Council 82 (C-82), January 2026 (opens in a new tab) — January 2026 (AAG-C-82-1/26). Printed page(s) 2, 3, 11, 12. New York State Department of Civil Service.
- CMS — No Surprises Act: ending surprise medical bills (opens in a new tab) — Reference listed October 17, 2026
Plan guides are summaries and can change. Your Empire Plan Certificate and Certificate amendments control. This page is general education, not medical, legal or benefits advice. Read our editorial standards.