Haris Ashley
Mental health issues are common, with half of US adults experiencing mental illness at some point in their lives. However, the cost of treatment can be a significant barrier to seeking help. While federal and state laws have been enacted to improve access to mental health services, the extent to which medical insurance covers mental health treatment varies depending on the type of insurance and the state in which it was purchased. In general, insurance companies are now prohibited from imposing more restrictive requirements for mental health benefits than for physical health benefits. However, insurance companies can deny claims if they deem that treatment was not medically necessary. This article will explore the coverage provided by different types of insurance plans and discuss options for individuals seeking mental health treatment.
| Characteristics | Values |
|---|---|
| Federal parity law | Applies to employer-sponsored health coverage for companies with 50 or more employees |
| Applies to coverage purchased through health insurance exchanges under the Affordable Care Act | |
| Does not apply to Medicare | |
| Does not apply to some state government employee plans | |
| Does not apply to health plans created and purchased before March 23, 2010 | |
| State parity laws | Vary by state |
| Colorado state law requires equal coverage for mental and behavioral health conditions and other medical conditions | |
| Colorado's Behavioral Health Care Coverage Modernization Act (2019) adds to the state's parity laws for private health insurance and the State Medicaid program | |
| Insurance coverage | Insurance plans subject to parity law cannot charge higher copays for mental health visits than for medical visits |
| Insurance plans subject to parity law cannot place limits on the number of mental health visits allowed in a year | |
| Insurance plans can deny claims if they determine that treatment was not medically necessary | |
| Insurance plans can place limits on mental health visits related to "medical necessity" | |
| Deductibles should apply to both mental and physical health coverage | |
| The Affordable Care Act requires that plans offered through health insurance exchanges cover services for mental health and substance-use disorders | |
| Medicaid programs are required to give equal access to mental health care | |
| The Children's Health Insurance Program (CHIP) provides insurance for families with children who don't qualify for Medicaid |
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What You'll Learn
Mental health parity laws
In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed, providing federal protections for certain types of health plans. This parity requires health insurance plans to cover mental health and substance use disorders similarly to medical and surgical benefits. The MHPAEA builds on the Mental Health Parity Act of 1996 (MHPA), which stated that large group health plans could not impose annual or lifetime dollar limits on mental health benefits that were less favourable than any such limits imposed on medical/surgical benefits.
The MHPAEA prohibits separate financial requirements and treatment limitations that apply only to mental health and substance use disorder (MH/SUD) benefits. This means that financial requirements, such as copayments/copays and deductibles, need to be similar in cost to medical/surgical benefits. It also ensures that yearly visit limits, needs for prior authorization, and proof of medical necessity are comparable.
The parity law also covers non-financial treatment limits. For example, limits on the number of mental health visits allowed in a year were once common, but the law has eliminated such annual limits. However, it does not prohibit insurance companies from implementing limits related to "medical necessity". The federal parity law generally applies to employer-sponsored health coverage for companies with 50 or more employees and coverage purchased through health insurance exchanges created under the Affordable Care Act.
While the MHPAEA provides important protections, it does not require group health plans or health insurance issuers to cover MH/SUD benefits. Some state parity laws may have stricter requirements than federal requirements, and it is important to check the specific regulations in your state. If your insurance plan isn't covering your therapy costs, you can appeal their decision to the Federal Center for Medicaid and Medicare Services or the U.S. Department of Labor, which can help enforce the parity law and get your therapy costs covered.
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Employer-sponsored health coverage
The Mental Health Parity and Addiction Equity Act (MHPAEA) ensures that employer-sponsored health insurance covers mental health services. This act applies to companies with 50 or more employees, requiring equal coverage for mental health and substance use disorder services as for medical/surgical services. This means that copays, deductibles, and treatment limits for mental health services cannot be more restrictive than those for physical health.
It is worth noting that the parity law does not mandate that plans include mental health benefits. However, if they do, the requirements and limitations for mental health coverage must be similar to those for physical health. This law has eliminated annual limits on mental health visits, ensuring better access to care. Additionally, the Affordable Care Act (Obamacare) requires that plans offered through health insurance exchanges cover mental health and substance use disorder services.
Employers are increasingly recognizing the importance of mental health coverage for their employees. According to Susan Blue, President and CEO of Community Services Group, "Mental health coverage, in particular, is one of those ways that we can say, 'yes, we really care.'" Employers are investing in their employees' well-being, and health insurance providers are playing a crucial role in this regard. They are providing mental health training to Primary Care Providers (PCPs) and improving access to telehealth services, making it easier for employees to seek support.
If you have employer-sponsored health coverage, it is essential to review your plan documents or contact your employer to understand the specific mental health benefits included in your plan. These benefits may include confidential therapy, substance use treatments, and access to recovery specialists. Additionally, employee assistance programs (EAPs) are often offered as a benefit to support mental health and address non-medical issues impacting work and home life.
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Medicaid and Medicare
Mental health benefits are provided for most Medicaid members through Prepaid Mental Health Plans (PMHP). Medicaid is the single largest payer for mental health services in the United States and plays an increasingly large role in the reimbursement of substance use disorder services. Congress has enacted several laws to improve access to mental health and substance use disorder services, including the Mental Health Parity and Addiction Equity Act (MHPAEA), which impacts the millions of beneficiaries participating in Managed Care Organizations and State alternative benefit plans.
Medicaid covers psychiatric rehabilitation, assertive community treatment, and peer support services for dual-eligible beneficiaries. It also covers outpatient mental health services for foster care children, which can be obtained from any Medicaid provider recommended by their caseworker.
Medicare Part B (Medical Insurance) covers certain outpatient mental health services, including:
- One depression screening per year, which must be conducted in a primary care doctor's office or clinic that can provide follow-up treatment and referrals
- Individual and group psychotherapy with doctors or certain other Medicare-enrolled licensed professionals, depending on the state
- Family counseling, if the main purpose is to aid treatment
- Testing to determine if the services and treatment are effective
- Psychiatric evaluation and medication management
- Certain prescription drugs that are not usually self-administered, such as injections
- Diagnostic tests, partial hospitalization, and intensive outpatient program services
Medicare covers a wide range of behavioral health services, including inpatient and outpatient programs. However, it does not cover psychiatric rehabilitation, assertive community treatment, or peer support services.
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Therapy costs and insurance
The cost of therapy can be a significant barrier for many people seeking mental health treatment. The average cost of one therapy session can range from $100 to $200, but this can vary depending on factors such as insurance coverage, location, and the therapist's level of experience.
Understanding Insurance Coverage for Therapy:
To determine if your insurance plan covers therapy costs, it's important to review your specific plan details. You can sign in to your member account or refer to your member ID card to understand your mental health care benefits. Some insurance plans may offer full or partial coverage for therapy sessions, while others may have specific exclusions or limitations. It's crucial to clarify any deductibles, copays, or restrictions associated with mental health services under your plan.
Parity Laws and Mental Health Coverage:
Parity laws play a crucial role in ensuring fair and equal treatment for mental health services. These laws prohibit health insurance plans from imposing more restrictive requirements or higher copays for mental health services compared to physical health services. The federal parity law applies to employer-sponsored health coverage for companies with 50 or more employees and plans purchased through health insurance exchanges under the Affordable Care Act. Additionally, state-specific parity laws, such as the Colorado State Legislature's Behavioral Health Care Coverage Modernization Act, further strengthen protections for mental health coverage.
Appealing Insurance Decisions:
If your insurance plan denies coverage for therapy costs, you have the right to appeal their decision. The process may vary depending on your insurance type, but you can generally reach out to entities like the Federal Center for Medicaid and Medicare Services or the U.S. Department of Labor for assistance. These organizations can help enforce parity laws and support your efforts to get therapy costs covered.
Alternative Options for Therapy Costs:
For individuals without insurance coverage for therapy, there are alternative options to consider. Firstly, you can explore therapy providers who offer reasonable rates or sliding scale fees based on financial need. Additionally, programs like the Children's Health Insurance Program (CHIP) and Medicaid can provide access to mental health services for those who qualify. County, state, and national programs are also available to help with medication costs related to mental illness.
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Accessing mental health services
Once you have a basic understanding of your coverage, you can explore the mental health services available to you. Many insurance plans offer behavioural health programs that can help with emotional struggles. These programs may include virtual visits, employee assistance programs, and other health and well-being resources. Additionally, some insurance companies may have a network of mental health providers that you can choose from.
When considering therapy, it is essential to ask the mental health provider if they accept your insurance. Inquire about their billing process and whether you will need to provide a copayment or submit a claim for reimbursement. The Affordable Care Act and federal parity laws have helped improve access to mental health services by requiring insurance companies to cover mental health, behavioural health, and substance use disorder services. These laws ensure that there are no higher copays or separate deductibles for mental health services compared to physical health services. However, insurance companies can determine what mental health treatment is considered a "medical necessity", and some claims may be denied based on this criterion.
If your insurance plan does not cover therapy costs or you face challenges in accessing mental health services, you have the right to appeal their decision. The process may vary depending on your insurance type, but you can reach out to entities such as the Federal Center for Medicaid and Medicare Services or the U.S. Department of Labor for support. Additionally, county, state, and national programs are available to help with medication costs related to mental illness through financial need-based discounts.
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Frequently asked questions
It depends on your health plan benefits. In the US, federal and state laws are in place to help people access mental health treatment. The Affordable Care Act (Obamacare) requires that plans offered through health insurance exchanges cover mental health and substance abuse services. The parity law also applies to most types of health insurance, including employer-sponsored health coverage for companies with 50 or more employees. However, some health plans are not subject to the parity law, including Medicare and some state government employee plans.
The parity law is a federal law that prohibits health plans from being more restrictive with mental health, behavioral health, and substance use disorder benefits than the medical and surgical benefits the plans offer. This means that insurance companies cannot charge a higher copay for office visits to a mental health professional than they would for a regular checkup at a doctor's office. The parity law also removes annual limits on the number of mental health visits allowed.
If your insurance plan isn't covering your therapy costs, you can appeal their decision. The way to appeal depends on your insurance type, but you can always appeal to the Federal Center for Medicaid and Medicare Services or the U.S. Department of Labor. You can also contact your state's Division of Insurance for help.
