Updated December 2025
Insurance reimbursement rates can make or break an addiction treatment or mental health program. Facility owners and billing leaders need enough revenue from Medicare, Medicaid, and commercial plans to sustain quality care while payer rules get more complex each year. In 2026, behavioral health remains underpaid compared with many medical specialties, but there are concrete strategies to protect margins and avoid leaving money on the table.
2026 snapshot: who pays what?
In 2026, behavioral health reimbursement still hinges on three pillars: Medicare, Medicaid, and commercial insurance.
Medicare
Pays for outpatient psychotherapy and psychiatric services under the Physician Fee Schedule, with national base rates adjusted by geography.
Newly recognizes licensed marriage and family therapists (LMFTs) and licensed mental health counselors (LMHCs) as independent billing providers, reimbursing them at 75% of the psychologist rate for covered services.
Continues to rely on CPT codes (e.g., 90791, 90832, 90834, 90837) and specific G‑codes for opioid treatment programs and brief interventions.
Medicaid
Is now the single largest payer for behavioral health services in the U.S., covering millions of adults with mental health or substance use disorders.
Typically reimburses outpatient psychiatric services at about 70–80% of Medicare rates on average, with wide variation by state and managed care plan.
Relies heavily on HCPCS H‑codes (e.g., H0001–H0040, H0010–H0019, H0015, H0038) for SUD and community‑based services.
Commercial insurance
Usually pays more than Medicare for many behavioral health services, sometimes 120–200% of Medicare benchmarks depending on region, contract, and code
Increasingly uses utilization management, prior authorization, and narrow networks to control spend, which can offset higher nominal rates if not managed carefully.
Parity laws require mental health and SUD benefits to be comparable to medical/surgical coverage, but enforcement is inconsistent, and underpayment and access gaps persist.
Coding foundations: CPT vs HCPCS in behavioral health
Behavioral health reimbursement starts with accurate coding. In 2026, the main frameworks are unchanged, but their use has become more scrutinized by payers.
CPT codes (AMA)
Used for psychotherapy, psychiatric evaluations, E/M visits, and many integrated care services.
Core examples for mental health and SUD:
90791 – Psychiatric diagnostic evaluation (no medical services).
90832 / 90834 / 90837 – Individual psychotherapy (30, 45, 60 minutes).
90853 – Group psychotherapy.
90839 + 90840 – Psychotherapy for crisis (first 60 minutes + each additional 30 minutes).
HCPCS Level II codes
Include the widely used “H‑codes” for SUD and community‑based services, especially in Medicaid.
Common examples:
H0001 – Alcohol and/or drug assessment.
H0004 – Individual behavioral health counseling, per 15 minutes.
H0005 – SUD group counseling.
H0010–H0014 – Detox services at various settings and acuity levels.
H0015 – Intensive outpatient program (IOP), per day.
H0018/H0019 – Short‑term and long‑term residential SUD treatment, per diem.
H0038 – Peer support services, per 15 minutes (in states that cover peers).
The key is to use the code the payer expects for that level of care and provider type, and to avoid double‑billing (for example, billing both a per‑diem program code and separate therapy codes for the same service day).
Payer rules that shape reimbursement
Reimbursement rates are only part of the story; payer policies determine how much of those rates you actually collect.
Medical necessity and prior authorization
Most payers require that behavioral health services meet their medical‑necessity criteria, often referencing ASAM levels of care for SUD and proprietary guidelines for mental health.
Higher‑intensity services (inpatient psych, residential SUD, PHP, IOP) almost always require prior authorization and concurrent review.
Failure to obtain or extend authorizations is one of the most common sources of preventable denials in addiction treatment and intensive outpatient programs.
Thorough documentation of symptoms, functional impairment, risk factors, and response to treatment remains essential to support the level of care billed.
Network status and contract terms
Whether you are in‑network or out‑of‑network dramatically affects reimbursement.
In‑network providers trade higher volume and simpler collections for lower contracted rates and stricter authorization rules.
Out‑of‑network providers may see higher chargemaster rates but more patient responsibility, higher denial risk, and growing payer restrictions, especially after federal surprise‑billing reforms.
Many behavioral health providers still cite low negotiated rates as a reason for staying out‑of‑network, but that can limit access and create cash‑flow volatility.
Rate differentials by payer
Across codes, the pattern that continues into 2026 is:
Medicaid < Medicare < Commercial, on average, with meaningful exceptions by state and payer.
In recent years, some states have raised Medicaid behavioral health rates or introduced value‑based incentives, but most still lag Medicare benchmarks.
Commercial plans may pay substantially more for the same psychotherapy code but can undercut that advantage with aggressive utilization management.
Benchmarking your facility’s average allowed amounts against Medicare’s fee schedule and available commercial rate data is critical to spot underpayment and negotiation opportunities.
Key code groups and what they mean for revenue
Assessment and diagnostic codes
Accurate intake coding sets the stage for correct downstream reimbursement.
90791 (CPT) – Psychiatric diagnostic evaluation by a licensed clinician; typically reimbursed once per episode per provider.
H0001 (HCPCS) – SUD assessment, used heavily in Medicaid SUD programs; often limited to one per admission.
96127 (CPT) – Brief behavioral assessment (e.g., PHQ‑9, GAD‑7); some payers reimburse multiple units per visit, others bundle it.
These are relatively high‑value services and frequent audit targets, so intake notes must clearly document history, mental status exam, diagnoses, and initial treatment plan.
Psychotherapy and counseling codes
Outpatient therapy codes are the backbone of many behavioral health revenue streams.
90832/90834/90837 – Time‑based psychotherapy codes; documentation must support the billed time range.
90853 – Group psychotherapy for mental health or SUD.
H0004/H0005 – Time or session‑based SUD counseling codes widely used in Medicaid and some commercial contracts for program services.
90839 + 90840 – Crisis psychotherapy with premium rates but strict criteria.
Commercial plans often pay more than Medicare for these codes, while Medicaid pays less but is a critical volume payer.
Detox, residential, and IOP codes
Higher levels of care rely on per‑diem program codes with strict authorization and documentation rules.
H0010–H0014 – Detox codes spanning inpatient hospital, residential, and ambulatory settings.
H0015 – Intensive outpatient program, per day, typically requiring ≥3 hours of structured treatment.
H0018/H0019 – Short‑term and long‑term residential treatment per diem.
H2036 – Generic SUD treatment per diem used by some payers in place of other H‑codes.
For these codes, “active treatment” is the expectation on every billed day. If progress notes do not show services delivered that day, payers may retrospectively deny or recoup payment.
Case management, crisis, and community codes
Many Medicaid programs and some grants reimburse for non‑therapy work that is essential to SUD and mental health outcomes.
H0006 / T1016 – Case management for SUD or mental health, often in 15‑minute units.
H0007 / 90839 – Crisis intervention, depending on provider type and payer.
H0030 – Behavioral health hotline services.
H0038 – Peer support, per 15 minutes, in states that cover certified peer specialists.
These codes can help finance the care coordination and outreach that often go unreimbursed under standard psychotherapy alone.
Practical ways to improve reimbursement in 2026
Even without changing payer mix, most organizations can raise net collections by tightening processes around coding, contracts, and data.
Standardize coding by level of care and staff role.
Map which codes are allowed by payer and by credential (e.g., which payers allow LMFTs/LMHCs to bill 90837 vs requiring H‑codes), and embed that logic into your EHR templates.Benchmark against Medicare and leading commercial schedules.
Compare your average allowed amount for common codes (90791, 90834, 90837, H0015, H0018) to Medicare rates and publicly discussed commercial averages; use that data in renegotiations and when deciding which plans to join.Track denials and underpayments by reason and payer.
Many preventable losses come from missing auths, exhausted visit limits, incorrect modifiers, or claims paid below contract; systematically categorizing and working these issues can materially raise net revenue.Use utilization review as a revenue‑protection function.
Proactive concurrent review, timely extension requests, and consistent documentation aligned with medical‑necessity criteria help preserve days of residential, detox, PHP, and IOP that might otherwise be cut.Explore enhanced and value‑based payments.
Some payers are piloting higher behavioral health rates tied to quality measures, collaborative care models, or crisis‑system participation; these can supplement fee‑for‑service reimbursement for providers able to meet reporting requirements.
How an EHR can support better reimbursement
An addiction treatment or behavioral health EHR designed around billing workflows can materially improve reimbursement outcomes.
Key capabilities that matter in 2026 include:
Built‑in code libraries for CPT and HCPCS H‑codes with payer‑specific rules and credential checks.
Automated prompts for required modifiers, place‑of‑service codes, and documentation elements (for telehealth, groups, and crisis visits).
Authorization tracking across levels of care (detox → residential → IOP → outpatient) with alerts before auths expire.
Denial management dashboards that highlight patterns by payer, code, and location so leaders can fix root causes.
Reporting that compares allowed amounts to contracted rates and to internal targets, enabling data‑driven contract strategy.
When these features are integrated into daily clinical and billing workflows, facilities are better positioned to secure appropriate reimbursement for the addiction and mental health care they already deliver.