Short answer: To keep your income up with inflation in 2027, raise your private-pay fee by $5 to $10 (or about the inflation rate) on a fixed date each year with 60 to 90 days' notice, and send a written rate-increase request to every insurance panel you're on, every year. Only 33.1% of therapists raised fees in 2025; those who did reported about $20,000 more in median revenue than those who didn't, per Heard's 2026 Financial State of Private Practice Report.

Why are your rates already going down?

If you haven't raised your fee since 2024, you've taken a pay cut. You just didn't sign anything.

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You already know this from the grocery store. The September 2026 CPI report put overall inflation at 3.7% for the year, with gasoline up 34%, coffee up 7%, electricity up 4.4%, and airfares up 22%. Groceries only climbed 1.8% this year, but they never came back down from the run-up before it. Consumer prices rose about 3% in 2024 and have run between 3% and 4% since. A $150 session set in early 2024 buys roughly what $137 bought then. Rent on your office went up. Your EHR went up. Your health insurance premium went up. Your clients are paying more for everything too, which is part of why raising your fee feels hard. The only number in your life that stayed put is the one you control.

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Most therapists know this and still don't move. In Heard's 2026 Financial State of Private Practice Report, 33.1% of therapists raised their fees in 2025. The ones who did reported median revenue of $94,792. The ones who didn't reported $74,979. That's a $20,000 gap in one year, and 62% said they had no plans to adjust fees in 2026.

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Dr. Marie Fang of Private Practice Skills put it plainly in the report: "If you're not raising your rate, you are effectively giving yourself a pay cut."

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This article covers three things. How to raise private-pay rates and tell your clients. How to ask insurance companies for more, and what to expect when you do. And what therapists are doing when neither of those is enough: sliding scales, superbills, hybrid panels, and leaving panels altogether. The second part is the one most rate-raising advice skips, and for the 74.6% of therapists who take insurance, it's the one that matters.

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What are therapists saying about fees and insurance rates in 2026?

The numbers first. Individual sessions ran $130 to $185 in 2025, and couples sessions $150 to $225. Insurance reimbursed $95 to $125 on average, 25% to 35% below private pay. A $150 cash session came back as about $105 through insurance. SimplePractice's data across 245,000 clinicians lands in the same place: an average self-pay rate of $139.75 against $99.75 from insurance.

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The mood is harder to put in a table. On r/therapists, the busiest fee thread of 2026 was a 327-comment megathread about Aetna cutting rates for Alma-contracted therapists. One commenter summed up the anger:

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"This is the only profession where we're expected to normalize pay decreases while everything inflates tf around us. We never get mad enough."
LICSW on r/therapists, May 2026

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Another drew the comparison that comes up again and again: "Most jobs will have a 2-6% salary increase annually to 'keep up with inflation' but reimbursement rates for private practitioners seem to stagnate."

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A Massachusetts therapist did the math on their BCBS contract in September: "Since I contracted with BCBS, I've seen an average annual raise of 2.23%. Average annual inflation over this period is 3.89%. I am making less, in real terms, than I did almost ten years ago."

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The private-pay conversations sound different. Less rage, more relief. The most common pattern in a May 2026 thread on how to raise fees was a small, scheduled bump every year. One therapist wrote: "In the first several years of my practice, I felt so bad about raising fees that I never did it, and was really undercharging for my skill level. For the past 5 years or so, I raise them every July by $10. No one has blinked an eye."

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And then there's the tension nobody has solved. A full-caseload therapist in November 2025: "I know I CAN raise my fees and be just fine, but I'm trying really hard not to in order to stay accessible to at least some people other than the purely wealthy." An MFT in the Aetna thread: "I absolutely hate that doing what I feel is the most ethical thing in refusing to accept insurance is also the biggest barrier I have to keeping my services affordable to all."

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Both things are true. You can want to be accessible and also need to pay your rent. The rest of this article is about doing both on purpose instead of by default.

How much should a therapist raise private-pay rates, and how do you tell clients?

Start with the number you need, then work backward. Take your income goal, add taxes, retirement, and business expenses, and divide by the number of sessions you can sustain per year without burning out. That's your floor. Heard's Session Fee Calculator does this math for you. If the number scares you, that's information too.

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How much. The therapists who do this every year without drama tend to move $5 to $10 at a time, or roughly the inflation rate. Allison Puryear of Abundance Practice Building has made the case for years: "If you see 20 clients a week and raise your rate $10 per session, that's almost $10K more you can put in retirement per year. $10 increases aren't something clients are likely to balk at." If you haven't raised in several years, you may need a bigger jump. Tiffany McLain, author of Lean In. MAKE BANK., argues for one across-the-board increase rather than a new-clients-only rate: "Always across the board."

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When. Pick a date and keep it. Several therapists on Reddit described the same system: every July 1, every January 1, same amount, same email. One LPC in Tennessee: "My policy is that everyone goes up by $5 every year July 1st (sliding scale included), but never exceeding whatever my full rate is at the time. I send out an email to everyone at the beginning of June reminding them of the change starting July 1st. I tell them that if that creates a barrier, let me know before the 1st." A fixed date turns a hard conversation into a calendar event.

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Notice. Give 60 to 90 days. Our full guide to raising your rates walks through the client conversation in detail. Dr. Marie Fang's long-standing advice: "A 90-day notice is customary, though not required." Say it in session, then follow up in writing. Keep the writing short. One therapist's entire script: "Hi [name], Effective [Date], I will be raising my rates to (number) an (time interval). Please feel free to contact me if you have any questions." Their note on it: "It really is that easy. It's normal for therapists to routinely raise rates."

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McLain's version is even shorter, from her December 2025 appearance on Heard's podcast:

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"Betty, I just want to let you know as of September 1st, my fee's going to be 250." And then, in her words, "you shut your mouth and Betty will have a reaction or not."
Tiffany McLain, Lean In. MAKE BANK.

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Don't explain. Don't apologize. Explaining invites negotiation.

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What happens next. Usually nothing. Fang: "I've found most clients are completely understanding that we need to raise our rates from time to time." A Reddit therapist who had just done it: "Generally my folks were like, 'Of course you should!!' There's always one person who has an opinion, but even that was fairly mild." Some clients will drop to every other week. A few will leave. One therapist framed it as useful: "I've found that raising my rates causes people to reevaluate the therapeutic relationship and what it may be worth to them. For some that means moving on to start fresh with new perspective of another clinician, and for others that means staying with a new level of engagement."

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Hardship exceptions. You can hold a client's rate if they're in a documented rough patch. Decide the rule before you announce the increase, so you aren't making it up under pressure in session. McLain's warning is worth sitting with: "If we keep our fees low because they can't afford it, that's codependence, that's toxic." You can disagree with how she says it and still hear the point. A blanket exception for everyone is a rate you didn't raise.

Can therapists negotiate insurance reimbursement rates?

Yes, you can ask an insurance company to raise your contracted rate, and you should, every year. Sometimes it works. Often it doesn't, and there's no way to predict which. Barbara Griswold, LMFT, who has written about insurance for therapists for two decades at Navigating the Insurance Maze, says it directly: "there seems to be no way to predict who will get raises." Her advice is to ask anyway, every year, and to "ask for $20 more than you are getting now for each type of service."

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Why asking is hard. You can't organize with other therapists to demand higher rates. Griswold again, from an April 2026 piece titled "Let's Go On Strike (Oh Wait, We Can't)": coordinating fees among independent providers runs into the Sherman Antitrust Act. So each therapist negotiates alone against a company with a legal department. Some payers, Aetna among them, only let you request a rate review once every one to three years. Some tell new providers not to ask at all. A newly licensed therapist in Florida was offered $68 for a 90837 in December 2025, down from the $102 the same company paid while they were under supervision, and reported: "the company was very explicit in their letter about saying we can't raise rates right now. Don't even try asking until you've been with us for a year."

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And rates can go down without warning. In 2026 alone, therapists on Reddit reported a quiet 10% cut from CareFirst BCBS in Maryland, a $15 to $20 per-claim cut from Premera in Washington for practices with ten or more clinicians, and a $70 per-session drop from Ambetter in Arkansas with no notice. The big one was Aetna, which flattened its 90837 rate to match shorter sessions and set a single rate across credentials for Alma-contracted therapists, effective July 15, 2026. A psychologist in that thread calculated a 40% cut. The American Psychological Association and the American Psychiatric Association sent a joint letter asking Aetna to pause.

How to ask anyway

The therapists who get increases share a few habits.

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Ask every year. A Utah LCSW with Cigna: "I currently get $88 for a 90837, but that is only because I ask them for a raise in rate EVERY year. I have been in practice for 12 yrs. They up it by as little as they can, $4-5 each year." Another started at about $65 with Cigna in 2021 and asked three years running: "I got it up to around $100. The last increase was literally like, $1, but the first two were significant."

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Put it in writing to the right person. Call provider relations and ask for the name and address of whoever handles fee schedule requests for your region. Send a letter, keep a copy, and set a reminder to follow up in 30 days.

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Make a business case. Maureen Werrbach of The Group Practice Exchange, who has asked for increases across her group's panels: "I make it a part of my job as a group practice owner to request fee schedule increases." Her letters cite years on the panel, specialties the network is short on, languages, after-hours availability, outcomes data, and the number of their members you see. Her results: "Most of these increases were upward of $15 per CPT code." Her framing: "It's on us as practitioners who take insurance to be assertive and request fair reimbursement rates."

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Know the market rate for your area. Transparency-in-Coverage data analyzed by Allia Health in 2026 put the median contracted rate at $96 for a 45-minute session and $138 for 60 minutes, with Aetna highest among large commercial payers and Cigna lowest. Heard's data has Aetna highest and Cigna lowest as well. If you're well below median for your credential and region, say so, with the number.

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Compare your direct contract to the platform rate. Therapists who left Headway or Alma and credentialed directly reported mixed results: "When I left Headway my Aetna went up, my UHC went up, my BCBS stayed the same and my Cigna dropped a lot. Overall I made more money leaving. YMMV. Find out for yourself." The reverse also happens. Dr. Ajita Robinson told Behavioral Health Business that CareFirst refused to review her 14-year-old direct contract but offered $17 more per session if she contracted through Headway instead. Her take: "I think it's unethical, but it absolutely should be illegal." Know which side of that you're on before you decide.

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When the answer is no. Ask when they next review rates and put it on your calendar. Ask whether a different credential, specialty, or certification would change the answer. Ask about single-case agreements for clients who want to keep seeing you. Then do the math on dropping the panel. One group practice: "After year 6 of denying rate increases we gave our notice and haven't looked back." A Reddit therapist's blunt summary of the whole landscape: "EAP rates are fairly easy to negotiate. Insurance rates are not."

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One state is changing the rules. Illinois's HB 1085 takes effect January 1, 2027. Per NASW Illinois, it requires state-regulated plans to reimburse behavioral health at no less than roughly 141.7% of the Medicare rate and bars insurers from auditing 90837 more aggressively than other codes. It doesn't cover self-insured employer plans. If you practice in Illinois, this is the year to ask. If you don't, it's the model advocates are pushing elsewhere.

What does the 2027 Medicare fee schedule mean for therapists?

Even if you don't take Medicare, its fee schedule matters, because many commercial payers set their rates as a percentage of it. Illinois's new floor is written that way.

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The proposed 2027 Medicare Physician Fee Schedule, released in July 2026, cuts the conversion factor 1.68% to $32.84. Most of that is the one-time 2.5% bump from 2026 expiring. The news for therapists is better than the headline: CMS's own projections show double-digit increases for clinical social work (about 12%) and clinical psychology (about 11%) because of changes to how practice expense is valued. Mental health telehealth flexibilities continue through the end of 2027. CMS finalizes the rule in November, so check the final numbers before you plan around them.

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The bigger picture: Medicare has no automatic inflation adjustment. Congress patches it year by year. Groups like MGMA are lobbying for an annual update tied to inflation. Until that happens, every year's schedule is a political decision, and the therapists who do best are the ones who read it each fall and adjust.

What other fee structures are therapists using to keep income up?

Raising a number is one lever. Changing the structure is another. Here's what therapists described using in 2026, with the tradeoffs.

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Hybrid: one or two panels plus private pay. The most common setup. 87.3% of insurance-accepting therapists in Heard's data also have a private-pay rate. The strategy is to keep the best-paying panel in your area as a referral pipeline and let everything else be private pay. One therapist: "I have one panel (Aetna) and it's ok. I self paneled, took about 6 months and a pain in the neck. A lot of my full pay clients are former insurance clients who left Aetna. I keep Aetna bc it's a back up pipeline to clients. But my private pay clients pay double what Aetna pays." Chicago group practice owners posting rate ranges in April 2026 put BCBS at $120 to $135, United at $100 to $120, and Cigna at $85 to $105. Pick your panel with numbers like those in front of you.

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Superbills and out-of-network billing. You set your rate, the client pays you, and their PPO reimburses them. A 20-year California therapist: "I mostly don't take insurance, however almost everyone on my caseload is reimbursed directly by their insurance companies. I submit all of my clients' claims for them via Availity and they get reimbursed and I never have to deal with insurance company or contracts." Their observation: "PPOs tend to reimburse much more to the client than they pay directly to the therapist." A Cigna provider found the same thing from the other side: "they reimbursed out of network for more than I got paid in network." The limit: it only works for clients with out-of-network benefits, which means PPO plans, which means it skews toward higher-income clients.

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A sliding scale with a formula. A sliding scale without rules becomes a discount for whoever asks. Kelley Stevens of The Private Practice Pro built hers around one number: "I charge what you earn for one hour of work." She capped the spots and ran the math first: "Doing the math meant I could get excited about offering these spots because I knew they were sustainable." Several Reddit therapists raise sliding-scale fees on the same schedule as full fees so the gap doesn't widen every year. Open Path Collective is the other route, with a set reduced rate and clients who come to you already knowing it.

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Leaving a panel. Sometimes the math says go. In the 2026 Financial State report, cash-only practices reported median revenue of $94K against $79K for insurance-accepting practices, though most of that gap went to higher marketing costs, and median profit was close: $58K against $55K. The APA's 2024 pulse survey found 34% of psychologists take no insurance, and of those who left or never joined, 82% cited reimbursement. The transitions people described in October 2026, after Headway announced a $9.99 per-session fee on marketplace referrals, went better than they feared: "Surprisingly, all of those conversations went smoothly! Clients were understanding. All but one plan to continue with me as private pay." Griswold's caution from the Aetna cuts applies here: "Don't make any rash decisions." Run the numbers on your caseload, by payer, before you send notice.

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Group practice splits. If you're a W-2 or 1099 clinician in a group, your rate conversation is about the percentage. A Chicago group owner's benchmark: fully licensed clinicians at 60% to 70% of collections, and "if you're fully licensed and good at your job you shouldn't accept under 65%." An LCSW offered a flat $31 per session in November 2025 asked Reddit if that was low. It was.

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What we didn't find. Packages and intensives come up in marketing, but we found little 2026 discussion of them among therapists on public forums. If you run them and they work, we'd like to hear about it.

How do you get past the guilt of raising your rates?

Every therapist we read described the same feeling before raising a fee, and most described it going away after. (Our 2024 guide goes deeper on guilt and imposter syndrome.)

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"Every time I have raised my rates, I'm squirmy about it in my head for a while. Then it's just what I charge."
Allison Puryear, Abundance Practice Building

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The guilt has a logic to it. You went into this work to help people, and a higher fee feels like a smaller door. But a therapist who is underpaid and overbooked is a worse therapist, and eventually a former one. A 16-year clinician in Los Angeles who took insurance across four states described bringing in about $70K a year with take-home "barely crossing 40k" and leaving private practice for a telehealth company. That's the version of accessibility nobody wants.

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Some things that help, from the people who've done it. Decide your rule for hardship cases ahead of time, so compassion is a policy you already wrote down. Put the increase on a calendar so it stops being a decision. Keep the announcement to two sentences. Expect a reaction, and let it be clinical material if it comes. One therapist noticed the increase changed the work itself: "When I raised my rates, clients began to be more attentive in session."

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And if what you're feeling is anger at a payer rather than guilt toward a client, that's a different thing. Griswold's point stands: you can't strike, but you can ask, in writing, every year. You can drop a panel. You can tell your state representative what Illinois did. Several of the most upvoted posts on r/therapists in 2026 were calls to organize around exactly that. The anger is reasonable. Point it at the contract, and keep your fee schedule moving while you do.

Frequently asked questions

How often should a therapist raise their rates?

Once a year, on a fixed date, is the most common and least stressful approach. Most therapists who do this move $5 to $10 per session or match the inflation rate, which ran between 3% and 4% a year from 2024 through 2026. If you haven't raised your fee in two or more years, a larger one-time increase may be needed to catch up.

How much notice should you give clients before raising your fee?

60 to 90 days is standard. Tell clients in session first, then confirm in writing with the new fee and the effective date. Keep the note to two or three sentences and invite questions. A 90-day notice is customary but not required by any licensing board.

How much do therapists charge per session in 2026?

Individual sessions ran $130 to $185 and couples sessions $150 to $225 in 2025, according to Heard's 2026 Financial State of Private Practice Report, which surveyed 1,950 therapists. SimplePractice's data across 245,000 clinicians put the average self-pay rate at $139.75. Rates vary widely by region, credential, and specialty.

How much does insurance reimburse therapists per session?

Between $95 and $125 on average for a standard session, or 25% to 35% below private-pay rates, per Heard's 2026 report. A $150 private-pay session typically reimbursed about $105 through insurance. Among large commercial payers, Aetna tends to reimburse highest and Cigna lowest, though Aetna cut rates for Alma-contracted therapists in July 2026.

Can a therapist negotiate reimbursement rates with insurance companies?

Yes. Send a written rate-increase request to the payer's provider relations or contracting department, citing your years on the panel, specialties, availability, and local market rates. Results vary and can't be predicted. Therapists who get increases usually ask every year; typical increases are $1 to $20 per code. Some payers limit reviews to once every one to three years.

Why can't therapists organize to demand higher insurance rates?

Independent providers who coordinate on pricing can run afoul of the Sherman Antitrust Act, which treats agreements among competitors on fees as price-fixing. That's why there's no therapist strike against a payer. Advocacy goes through professional associations and state legislation instead, such as Illinois's HB 1085, which sets a behavioral health reimbursement floor starting January 1, 2027.

Should a therapist drop insurance panels and go private pay?

It depends on your caseload, your market, and your marketing budget. Cash-only practices reported median revenue of $94K in 2025 against $79K for insurance-accepting practices, but most of that gap went to higher marketing costs, and median profit was close: $58K versus $55K. Run the numbers by payer before giving notice, and consider keeping your best-paying panel as a referral source.

What is a superbill and how does it help therapists keep rates up?

A superbill is an itemized receipt a client submits to their insurance for out-of-network reimbursement. You set your full rate, the client pays you directly, and their PPO reimburses them a portion. It lets you avoid contracted rates while clients still use their benefits. It only works for clients with out-of-network coverage, which usually means PPO plans.

Raise it before you're ready

There's no year where this feels comfortable. 2027 will have its own reasons to wait. Pick a date, pick a number, send the note. If you take insurance, send the other note too, the one to provider relations, and set a reminder to send it again next year.

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If you want help with the math, Heard's Session Fee Calculator works backward from your income goal. If you want help with the rest, that's what we do.

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This post is for informational purposes and does not constitute legal, business, or tax advice. Consult your own professionals.

Sources

Heard, 2026 Financial State of Private Practice Report

U.S. Bureau of Labor Statistics, Consumer Price Index, September 2026

SimplePractice, State of Private Practice 2025

APA, 2024 Practitioner Pulse Survey

Behavioral Health Business, Allia Health reimbursement analysis, June 2026

Behavioral Health Business, Aetna cuts rates for Alma therapists, May 2026

APA Services, joint letter to Aetna, June 2026

Behavioral Health Business, Dr. Ajita Robinson on CareFirst and Headway, May 2026

ClearHealthCosts, Headway $9.99 fee, October 2026

HFMA, 2027 Medicare Physician Fee Schedule proposed rule

NASW Illinois, summary of HB 1085

Barbara Griswold, Let's Go On Strike (Oh Wait, We Can't), April 2026 · Are Raises Possible? · Aetna flattens Alma providers, May 2026

Heard podcast, Raising Your Fees Without Losing Clients with Tiffany McLain, December 2025

Marie Fang, Sample Rate Increase Letter · Allison Puryear, Is it Time to Raise Your Rates? · Maureen Werrbach, Requesting a Fee Increase with Insurance Companies · Kelley Stevens, Sliding Scale Therapy Guide

r/therapists threads: Aetna/Alma megathread · Cigna $59 for 90837 · How do you raise fees? · BCBS MA non-raise · BCBS lowered rates · Premera WA · Ambetter · Low rate for newly licensed · Negotiating reimbursement rates · Leaving Headway · How to make a living in PP · Navigating pay in group practice · Cutting costs · How are you surviving · Clients expecting nights and weekends

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