Coverage
Outpatient, PHP and IOP coverage under NYSHIP
The 2026 guides say network outpatient services, including outpatient substance use rehabilitation programs, may have a $25 copayment per visit. Non-network outpatient care is paid at 80% of the plan's allowed amount after the combined annual deductible, and you owe the balance.
Published by the NYSHIP.rehab editorial resource · Updated
What is the difference between outpatient, IOP and PHP?
| Level | Typical time commitment | Who it often suits |
|---|---|---|
| Standard outpatient | One or a few sessions a week | Stable people continuing work or school |
| Intensive outpatient (IOP) | Several hours, several days a week | People needing more structure while living at home |
| Partial hospitalization (PHP) | Most of the day, most weekdays | People stepping down from inpatient care or needing near-daily clinical care |
Outpatient programs often combine counseling with medication management. For substance-specific detail, see counseling-based treatment for cocaine and stimulants and medications for opioid use disorder in outpatient care.
What do network outpatient programs cost?
Both guides state that office visits and other outpatient services — listing outpatient substance use rehabilitation programs as an example — may be subject to a $25 copayment per visit (printed p. 12). "May" matters: confirm how your program bills, especially for multi-hour IOP or PHP days.
Network copayments count toward the in-network out-of-pocket limit for the Hospital, Medical/Surgical and MHSU programs. See 2026 limits and deductibles.
How is non-network outpatient care paid?
- You first meet the combined annual deductible ($1,250 per enrollee, spouse/partner, or all dependent children combined in both 2026 guides).
- The plan then pays 80% of the allowed amount — not 80% of the bill.
- The allowed amount is based on 275% of published Medicare rates for the same or similar service in the geographic market.
- If the provider bills more than the allowed amount, the difference can add to what you owe.
Worked examples are in our rehab cost guide and out-of-network guide.
Is virtual (telehealth) IOP covered by NYSHIP?
The 2026 At A Glance guides describe outpatient MHSU benefits but do not set out separate rules for virtual IOP, so we cannot say it is always covered. The same steps apply as for in-person care: call the MHSU Program, confirm the virtual program is in The Empire Plan network for that service, and confirm what needs to be certified as medically necessary (printed pp. 11–12).
Questions to ask a virtual IOP
- Are you licensed to treat patients located in New York State?
- Are you in The Empire Plan network for virtual IOP, and how do you bill each session day?
- What happens if I need in-person care, medication management or a higher level of care?
- What is your crisis plan between sessions?
What should you ask an outpatient program?
Outpatient program questions
- Are you in The Empire Plan network for IOP/PHP, not just for office visits?
- How is a program day billed — one visit, or several services?
- Does the program request certification, and how often is it reviewed?
- Do you offer evening sessions or telehealth to fit around work?
- Can you coordinate with my prescriber if medication is part of treatment?
Outpatient care is also a common way to continue treatment after inpatient rehab. If you are worried about your job, see rehab privacy and employment.
Frequently asked questions
Does the Empire Plan cover virtual IOP?
The 2026 guides do not give separate virtual IOP rules. Call the MHSU Program to confirm the program is in network and the services are certified as medically necessary before you start.
Is IOP covered by NYSHIP?
Outpatient substance use rehabilitation programs are listed among outpatient services that may have a $25 network copayment, when certified as medically necessary. Confirm network status and certification for the specific IOP.
Do outpatient copays count toward a maximum?
Network copayments count toward the in-network out-of-pocket limit. Copayments to MHSU network practitioners also count toward the combined annual coinsurance maximum, while copayments to network facilities do not (printed p. 3).
Related guides
- 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.
- 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.
- GuidesRehab, privacy and your job: what the rules generally protectWhat HIPAA, 42 CFR Part 2 and the ADA generally protect for employees seeking addiction treatment, and their real limits. No guarantees.
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, 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, 12. New York State Department of Civil Service.
- NIDA — Treatment and recovery research topic (opens in a new tab) — Accessed 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.