Full parity of health insurance benefits for treatment of mental illness, including substance use disorders, is a major achievement. However, the newly-published regulations implementing the legislation strongly endorse aggressive managed care as a way of containing costs for the new equality of coverage. Reductions in “very long episodes of out-patient care,” hospitalization, and provider fees, along with increased utilization, are singled out as achievements of managed care. Medical appropriateness as defined by expert medical panels is to be the basis of authorizing care, though clinicians are familiar with a history of insurance companies' application of “medical necessity” to their own advantage. The regulations do not single out psychotherapy for attention, but long-term psychotherapy geared to the needs of each patient appears to be at risk. The author recommends that the mental health professions strongly advocate for the growing evidence base for psychotherapy including long-term therapy for complex mental disorders; respect for the structure and process of psychotherapy individualized to patients' needs; awareness of the costs of aggressive managed care in terms of money, time, administrative burden, and interference with the therapy; and recognition of the extensive training and experience required to provide psychotherapy as well as the stresses and demands of the work. Parity in out-of-network benefits could lead to aggressive management of care given by non-network practitioners. Since a large percentage of psychiatrists and other mental health professionals stay out of networks, implementation of parity for out-of-network providers will have to be done in a way that respects the conditions under which they would be willing and able to provide services, especially psychotherapy, to insured patients. The shortage of psychiatrists makes this an important access issue for the insured population in need of care.