Out-of-Pocket Therapy Visits Average Nearly $175 an Hour

Only one-third of Americans with a behavioral health condition received treatment within a year of their diagnosis.

That’s based on a new analysis of 2021 data by the actuary and technology consulting company Milliman; the nonprofit Inseparable commissioned the research. The resultant report paints a picture of how and where Americans are cut off from the behavioral health system. While some regions and certain health plan members have more access to care than others, none show adequate access and utilization.

“While access is a complex topic and involves additional considerations beyond those included in this report, many metrics for which data are available point to aspects of access that could potentially be improved,” the report states.


Within payer types, the national safety net health plans feature the highs and lows of access and utilization.

Medicaid members had the highest rate of getting behavioral health care post-diagnosis in 2021, at 44%. Fee-for-service Medicare, also known as traditional Medicare, saw the lowest rate at about 16%. The commercial health plan member rate was about 31%.

“While some individuals receive appropriate treatment through primary care or other types of providers, this high percentage of individuals diagnosed with behavioral health conditions not receiving treatment from a behavioral health specialist indicates a significant gap in care,” the report states.


There is a substantial disparity between the large population of people who need behavioral health care and the much smaller population that actually receives care. In short, it comes down to many people thinking they don’t need treatment.

The latest National Survey on Drug Use and Health (NSDUH), a massive federally backed survey on America’s behavioral health, found that the top two reasons for this are believing that the respondent should be able to handle their condition on their own and then not being ready to start treatment.

The report explores the behavioral health provider shortage, examining federal data that shows that most Americans live in areas that are considered to be service shortage areas. The report also found that residents in states with low access have much lower utilization rates than those in states where care is more readily available.

“For example, Florida has one of the lowest behavioral health provider supply ratios,” the report states. “Individuals with behavioral health conditions living in Florida only received 22.7% of the number of therapy visits that they would have received if they had received care at the same rates as those living in areas with the highest provider supply in 2021.”

Paying out of pocket for therapy

The report used a 60-minute psychotherapy visit to compare the out-of-pocket costs across payer types. However, it excluded Medicaid, because t these costs are “generally nominal and are not reported.”

Self-pay for those not using health insurance was $174.46. Louisiana had the highest rate at $286.89, while South Carolina had the lowest at $93.92 per visit.

Out-of-network providers for commercially insured patients generate more than double, by about 2.3-times more, the out-of-pocket costs: $52.87.

Out-of-network behavioral health care

The report looked at what share of behavioral health care costs come from out-of-network services based on care type and state.

“Out-of-network services often come with higher patient cost sharing requirements and may necessitate additional steps for coverage approval,” the report states. “The percentage of care provided out of network may serve as an indicator of the adequacy of commercial insurance networks in providing patients with access to in-network care.”

Across the board, about 16% of all behavioral health costs come from out-of-network care.

There is a massive spread among the states that have the least and most behavioral health costs coming from out-of-network care. On the high end, New Jersey saw about 50% of all costs come from out-of-network care. Meanwhile, that figure is 2% for Hawai’i and South Dakota.

Even among the states with the highest share of costs coming from out-of-network care, the top four — three of which are the Eastern Tri-State — stand out from the rest. Both Connecticut and New York come in at about 47% while South Carolina shows 44%.

Previous Milliman research found that behavioral health is not provided on an in-network basis in parity with physical health care. In a now-seminal study, the firm reported in 2019 that behavioral health providers were 5.7 times more likely to be out-of-network than their physical health care peers. Behavioral health office visits were between seven- and 11.5-times more likely to be out of network than primary care office visits in the states with the largest disparities.

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