Why Is It So Hard to Find an Affirming Therapist Who Accepts My Insurance?

If you’ve ever searched for an in-network therapist who truly “gets it”—someone inclusive, LGBTQ-affirming, neurodivergent-friendly, and respectful of your identity who is also in-network with your insurance—you’ve probably felt frustrated. More often than not, many affirming providers do not participate with insurance.

It’s not because they don’t care about accessibility. The reasons are structural, messy, and deeply tied to how therapy and mental health services are paid for in the U.S.

Let’s break down why this mismatch exists—and why it’s not as simple as it looks.

The Medical Model vs. the Social Model

Insurance is built on the medical model: every therapy session that insurance is billed for requires a diagnosis code. This frames distress and difference as pathology. Through the medical model lens, having a diagnosis frames your experience as a mental health disorder to be treated or fixed.

By contrast, many neurodiversity-affirming therapists ground their work in the social model of disability, which emphasizes that difficulties often arise from environments, systems, and expectations—not from you being “broken.” When we think of diversity, including gender expansiveness and neurodivergence, from the social model of disability, we see it as part of the natural range of human experiences. The discomfort and difficulties that arise typically relate to a mismatch—or absence of needed supports—in the existing environment.

Here’s the rub: affirming therapists often don’t see their clients as “disordered,” but if a therapist wants to work with insurance, they must assign a diagnosis. That creates tension between a values-based philosophy of affirming diversity and the reality of the medical model that codes difference as deficits.

Why Many Therapists Don’t Accept Insurance

• Payment delays and financial risk: Insurance companies may take weeks or months to pay, and can even demand money back through “recoupment” if the insurance company doesn’t agree with the therapist’s assessment that therapy is a medical necessity. For therapists without financial reserves, this can be devastating.

  
  

• Confidentiality limits: Insurance participation opens the door to auditing a therapist's documentation, which means more people may have access to a client's sensitive information. Diversity-affirming therapists may be particularly sensitive to these limits when identity and mental health become scrutinized in the political context.

  
  

• Unpredictable income: Private pay therapists can charge clients for the time reserved on their calendars, even if the client is a "no show". In contrast, insurance pays only for the time the therapist spends with the client. This means that late arrivals can create a significant reduction in how much a therapist earns. While cancellation fees can be charged to clients with commercial insurance, no out-of-pocket fees can be billed to Medicaid clients—which means therapists may reserve time in their schedules for which they receive no reimbursement. Many therapists may find this unpredictability unsustainable.

  
  

• Philosophies of Care: There’s good evidence that the therapeutic relationship is the most powerful factor impacting a client’s overall therapy experience. All people, regardless of diagnostic criteria, are likely to benefit from a therapeutic relationship in which the focus is on our messy, human experience. Some therapists, including those who aren’t immersed in “affirming care” language, prefer to focus on this relational human healing experience, instead of treatment planning (required by insurance) and diagnosis. While many therapists view their work this way, it’s most common among those working with couples who view the relationship—not an individual—as the focus of services. This conflicts with insurance requirements for an individual diagnosis to guide a treatment plan.

The Particular Challenges for Affirming Therapists

By and large, the terrain of neurodiversity-affirming and LGBTQIA+-affirming therapists tends to be occupied by clinicians with shared lived experience with the communities they serve. That shared lived experience often connects to why affirming therapists are so passionate about their work. It also means that affirming clinicians are impacted by structural realities of power and privilege.

I enjoy talking with therapists as they plan to open their practices, and I remember a conversation where a therapist explained that taking Medicaid was the ethical choice which they were making from a place of “my social work values”—right before mentioning that their office space came courtesy of open office space in their spouse’s successful technology company. I couldn’t help thinking, "I’d have a lot more ethical choices available too if rent wasn’t on my balance sheet."

Mental health professionals from historically underrepresented communities are less likely to have the same financial cushions. We tend to frame access as a client-facing question: How will the client access therapy? Within this frame, insurance is positioned as the solution.

But there’s an often-overlooked question of how accessible the profession is to the professional. Does accepting insurance afford the professional the security and sustainability to keep their doors open? Keep food on their table? Grant themselves the self-care and nurturing needed to prevent burnout and continue showing up for clients?

Beyond financial accessibility and ethical conflicts, there’s also a question of whether the organizational requirements of insurance billing are accessible for diverse individuals. Neurodivergent people can undoubtedly benefit from working with therapists who share lived experience. Few can validate and normalize like others who have lived it. But the billing requirements of insurance may not support the ways in which neurodivergent clinicians function.

We often frame a choice as the ethical option, when what it actually represents is a dilemma—when two or more values are in conflict. In a dilemma, there’s no perfect option. Therapists are constantly weighing accessibility, sustainability, privacy, and integrity, and what looks obvious from the outside is rarely so simple.

Why Some Therapists Choose To Take Insurance (Despite the Challenges)

Let’s start with a shared understanding that all therapists, like all people, have different resources and different risk tolerance. What might shut the doors for one practice may be a workable inconvenience for another. Some therapists acknowledge the risks and ethical imperfections of accepting insurance and make the choice from a place of calculated clarification that doing so is the best option for them and their clients.

Potential benefits of participating in insurance may include:

• Lowering barriers for clients who can’t afford private pay.

• Aligning with therapist values around accessibility.

• In underserved areas, it may feel essential to increase options for marginalized communities.

  
  

How well this works for any therapist, or practice, relates to their particular resources. In group practices, these decisions may often also reflect how the practice prioritizes the pay of their therapists. Therapists working in large, investor-backed organizations may face particular challenges where bottom-line-driven financial pressure can inhibit setting healthy boundaries. In addition, newer therapists who have not yet clarified their financial needs may be especially vulnerable to feeling pressured into choices that don’t ultimately support their sustainability.

Often when therapists participate in some insurance plans but not others, that choice is guided by how insurance companies treat (or support) providers and how much they reimburse them for their work. If you have a choice of what insurance plan to enroll in, you might start by exploring which plans are accepted by providers you’re interested in working with.

What This Means for You When Looking For a Therapist

If you’re struggling to find an affirming therapist who takes insurance, know this: it’s not a reflection of your worthiness, and it’s not that affirming therapists don’t want to serve you. It’s that the system itself is mismatched with affirming practice.

Some things you might try:

• If you have choices related to what insurance company to enroll in, explore what plans are accepted by providers you are interested in working with.

• Ask providers if they offer sliding scale, equity model pricing (where fees are adjusted based on income or privilege), or limited reduced-fee spots. More therapists are considering what accessibility could look like outside of an insurance model. This is most common with solo private practice therapists who make their own decisions and have direct authority to create policies and make exceptions.

• Explore out-of-network reimbursement if your plan allows it. Be aware that the same confidentiality limits that apply to in-network therapists may also apply to using out-of-network benefits.

• Look into community resources (nonprofits, mutual aid, or group supports) that can help bridge the gap.

While no one person is responsible, or individually able, to change the existing system, your voice can contribute to collective action. If you have the time and resources, you might consider contacting your state and federal representatives and letting them know how you are impacted by issues related to mental health access. Solutions are needed that support therapists in offering more accessible services while maintaining the wellbeing of the people providing them.

The frustration is real. The reality is structural. And the choices therapists make are often about navigating dilemmas, not failing to live up to values. While there’s no perfect fix yet, more affirming providers are working to create accessible options—balancing care, sustainability, and integrity along the way.

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Helen Dempsey-Henofer LCSW ADHD-CCSP

Founder & Clinical Director - Divergent Path Wellness

To learn more about working with Divergent Path Wellness, including what insurance plans we currently accept, please visit our website. We provide intentional, inclusive therapy to adults and teens, ages 14+, across Virginia.