What Kinds of Mental Health Care Does Health Insurance Cover?
Today's health insurance plans do a better job than ever of covering mental health services and treatments. Here's why and how they provide that coverage.
According to the National Alliance on Mental Illness (NAMI), just about 20 percent of adults in the U.S. experience mental illness in a given year.
That means nearly 44 million American adults will deal with a mental health issue at some time.
Mental illness impacts millions of children and young adults, too. NAMI estimates around one in five youth between the ages of 13 and 18 face a mental disorder during their lives. The same is true of approximately one in eight children ages eight to 15.
That's a stark reality. If left untreated, mental illness can make life even more difficult for those it affects.
For example, NAMI reports over one-third of students with a mental health issue drop out of school. Worse, mood disorders are the third most common cause of hospitalization among Americans. And suicide is the 10th leading cause of death in the U.S.
Thankfully, mental illness doesn't have to go untreated if you have health insurance. Not all policies cover all forms of mental health care, but most policies cover a wide range of services and treatments.
The ACA, The MHPAEA, and Mental Health Coverage
Americans can thank two pieces of legislation for the fact that most health insurance plans cover a wide range of mental health services, treatments, and drugs.
One is the Mental Health Parity and Addiction Equity Act (MHPAEA). The other is the Affordable Care Act, otherwise known as the ACA or Obamacare.
The MHPAEA, passed in 2008, extended 1996's Mental Health Parity Act. It outlaws discriminatory practices that limit insurance coverage for behavioral health treatment. Specifically, it requires coverage for mental health and substance-use disorders to be no more restrictive than coverage for physical health.
The Affordable Care Act took things even further. Signed in 2010, it required most individual and small employer health insurance plans to cover mental health services.
Together, these two laws made health insurance coverage available to more Americans than ever. They also expanded the scope of that coverage to include mental health benefits.
More about the MHPAEA and Mental Health Coverage
What does all of this mean for someone who needs professional help with a mental health issue?
For starters, the MHPAEA says insurers need to treat coverage of mental and physical health services equally. It applies to these services:
- Deductibles, copayments, coinsurance, and out-of-pocket limits
- Limitations on how much or how often a policyholder can use a particular service
- The use of care management tools
Don't worry if one or more of these bullet points confuses you. Here's what they mean in a real-world situation:
Pretend an insurance company charges you a copay of a certain amount for visiting a physician or surgeon. The insurer has to charge the same copay for visiting a psychologist or other mental health specialist. In other words, your insurer can't charge you a higher copay for seeing a psychologist than seeing a physician.
Also, an insurance company can't place limits on how many times you visit a mental health professional. It also can't limit the number of days you spend as a hospital inpatient. Both were allowed before MHPAEA.
The law says insurers must treat care management tools similarly, too. They can't force you to get authorization for a mental health treatment if they don't also force you to get it for treatment for your physical health.
More on the ACA and Mental Health Coverage
As for the Affordable Care Act, here are some of the requirements it levels at insurance companies.
Most health plans must now cover preventive services at no additional cost. Depression screening for adults and behavioral assessments for children are two examples of preventative services.
Also, most plans can't deny coverage to someone with a pre-existing condition. This includes people with pre-existing mental illnesses or disorders. And they can't put yearly or lifetime dollar limits on coverage of any "essential health benefit." This includes mental health services.
Obamacare's broadest impacts are in the requirements for plans sold through the insurance marketplace and exchanges. All such plans must cover behavioral health treatment like psychotherapy and counseling, as well as mental and behavioral health inpatient services.
New Laws Don't Impact all Insurers and Health Plans, But Do Impact Most
ACA and the MHPAEA don't force all insurers and policies to cover mental health treatments and services.
Their restrictions and requirements do apply to a wide range of plans, however, including the following:
- Policies bought through federal or state health insurance exchanges
- Children's Health Insurance Program (CHIP) plans
- Coverage offered through most Medicaid programs
The MHPAEA requirements also apply to job-based health coverage for companies with 50 or more employees. But they don't apply to Medicare plans.
Which isn't to say Medicare plans don't cover mental health services or treatments. This article--"What Kinds of Mental Health Care Do Medicare and Medigap Cover?"--explains more.
The MHPAEA requirements also don't apply to some plans provided to state government employees. This includes teachers and employees of state universities.
MHPAEA requirements related to Medicaid coverage of mental health care can vary from program to program. To see if this law applies to your program, contact your state's Medicare director.
Mental Health Care Coverage Advice
It's easy to get confused while figuring out if an insurance policy covers a certain mental health care service or drug. Follow this advice, though, and you'll keep confusion to a minimum.
Look at your plan's "Summary of Benefits and Coverage." This should be the first step you taken when trying to figure out if your health plan covers a service, treatment, or drug.
If that doesn't help, and if you get your insurance through an employer, talk to someone in human resources.
You're next step if your HR contact fails you: contact your insurer directly.
Before you make an appointment with a mental health care provider, ask them if they accept your insurance.
Also, make sure you're fully aware of your copays and deductibles before you see a specialist.
Frequently Asked Questions
Q: Do insurance companies have to cover all kinds of mental health care?
A: No, they don't. Private insurance companies don't have to cover mental health care at all. If they do provide this coverage, though, it can't be more restrictive than the coverage they provide for physical health care.
On a related note, health insurers don't have to cover certain mental disorders or illnesses. To find out if that's true of your plan, look over its "Summary of Benefits and Coverage." It will explain any exclusions. And if it doesn't, contact your insurance company.
Q: How can I find out if my insurance policy covers mental health care?
A: The first thing you should do is take a look at your policy's "Summary of Benefits and Coverage." It should tell you if it covers mental health services or treatment.
If you get your health insurance from an employer, ask your company's HR department for assistance. If he or she can't help, or if yours isn't a job-based health plan, call your insurer directly.
Q: What if my health insurance plan doesn't cover mental health services and treatment? Is there anything I can do?
A: You get your health insurance through an employer, right? If so, this doesn't mean your insurer violating the laws mentioned earlier.
The MHPAEA doesn't require insurance companies to cover mental health services, treatments, or drugs. It just says that if they do cover mental health care, the requirements for that coverage can't be more restrictive than that of physical health care.
Given that, your best bet here is to talk with someone in your company's HR department. Ask them to consider other health insurance options in the future. Or you can look elsewhere for a plan.
If you get your health insurance through the federal marketplace or a state exchange, something must be wrong. Thanks to the Affordable Care Act, plans sold through these sites have to cover mental health services and treatment.
Q: My insurance policy covers mental health care, but my psychologist won't accept it. Why?
A: Mental health care providers don't have to accept health insurance. In fact, many don't--and for a number of reasons. So, if your psychologist or other specialist won't accept your insurance, look for one who does.
Do you get your health insurance from your employer? If so, talk with someone in HR about considering other options in the future.
Q: If the Affordable Care Act is repealed and replaced, will it impact my mental health care coverage?
A: The short answer here is "it could." It's difficult to say for sure, though, because the ACA remains in place. Also, Republicans in Congress have proposed a number of Obamacare replacements so far. At least some of them would negatively impact insurance coverage of mental health services and treatments if passed.
The American Health Care Act (AHCA) is one example. According to The Atlantic, the AHCA affects coverage of mental illnesses in that it allows states to "essentially eliminate mental-health parity in exchange plans."
AHCA proposes establishing a $15 billion fund for maternity care, mental health, and substance abuse treatment. But the Congressional Budget Office (CBO) isn't a fan of it.
“Out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for the non-group enrollees who would use those services,” says a CBO report.
Whether or not something like the AHCA eventually replaces Obamacare is still up in the air. If one does, though, it's possible--maybe even likely--it would impact mental health care coverage in some way.
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