Jeffrey Wade
Mental health issues are common, with one in six adults in California experiencing some form of mental illness. Fortunately, if you have health insurance, there are federal and state laws that ensure you receive the necessary care. While coverage depends on your insurance company, state, and healthcare provider, most health insurance plans cover individual therapy and counseling. This includes outpatient diagnosis and treatment, inpatient hospital services, partial hospitalization, diagnosis, outpatient services, and prescription drugs. Some insurance companies may also cover telehealth services for therapy, although this is not always the case. If you are unsure about your coverage, your health insurance plan's website should contain information about your coverage and the costs you can expect.
| Characteristics | Values |
|---|---|
| Location | In California, federal and state laws ensure that people with health insurance receive the necessary care for mental health and substance use disorders. |
| Coverage | Most health insurance plans cover individual therapy and counseling, but the coverage varies depending on the insurance company, state, and healthcare provider. |
| Types of Therapy Covered | Inpatient treatment, substance use treatment, counseling, and telehealth services. |
| Professionals Covered | Primary care providers, behavioral health providers (therapists, psychologists, psychiatrists, licensed mental health counselors, and licensed independent clinical social workers), and clinical social workers. |
| Cost | Some plans have a co-pay, where a set amount is paid for each appointment, while others are deductible plans, where medical expenses are paid up to a certain amount before insurance covers a specific percentage. |
| Finding Coverage | Covered California's Compare and Select a Plan tool can help find the right health plan. |
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What You'll Learn
Inpatient and outpatient treatment
Inpatient mental health services are those received in a hospital or rehabilitative setting. Most insurance plans will cover inpatient treatment, but the length of stay may be limited, or there may be a cap on the amount the insurer will pay. Medicare Part A covers inpatient behavioral health and substance use services. If you are hospitalized, you may have a deductible per benefit period as well as coinsurance costs.
Outpatient mental health services involve diagnosing and treating people with mental health conditions, like depression and anxiety. Outpatient treatment includes individual and group psychotherapy, family counselling, psychiatric evaluation, medication management, and diagnostic testing. Medicare Part B covers outpatient mental health services, including an annual depression screening. However, you may have out-of-pocket costs for therapeutic services, including the Part B deductible, copays, and coinsurance.
The breadth of coverage for specific therapeutic treatments varies from plan to plan, as does the coverage and cost of medications. Many insurance plans cover some amount of therapy, but they usually only cover treatments that are considered medically necessary. This means that insurance companies may cap the number of therapeutic visits they will pay for annually unless a therapist or other professionals state in writing that they are medically necessary.
If you are seeking mental health treatment, it is important to check with your insurance provider to understand what is covered and what your costs will be. If your insurance plan is not covering your therapy costs, you can appeal their decision. There are also county, state, and national programs available to help with the cost of medication related to mental illness.
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Substance use treatment
Mental health services, including substance use disorder treatments, are covered by some medical insurance plans. In the US, the Affordable Care Act requires a set of ten categories of services that health insurance plans must cover, including mental health services. This means that limits applied to mental health and substance abuse services cannot be more restrictive than limits applied to medical and surgical services.
Medicare, for example, covers a wide range of behavioral health services for substance use disorders, including inpatient and outpatient treatment. Medicare Part B (Medical Insurance) specifically covers mental health services for substance use disorder treatment, including individual and group psychotherapy, family counselling, psychiatric evaluation, medication management, and prescription drugs.
Employer-sponsored health plans may also provide coverage for substance use disorder treatment, including access to confidential therapy, various treatment options, and recovery specialists. These plans often include inpatient and outpatient treatment services, with follow-up case management, personalized coaching and support programs, and referrals to local community support groups and online resources.
It is important to review your specific insurance plan to understand the costs and details of your coverage, as all plans have exclusions and limitations. For example, some treatments may require prior approval by your insurance provider before receiving coverage. Additionally, if you are in Texas, the Texas Health and Human Services can help you access substance use treatment through your insurance plan and provide assistance with insurance claims and complaints.
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Counselling and therapy
Most health insurance plans cover individual therapy and counselling to some extent. However, the specific coverage and costs can vary significantly between plans. Some plans may have a deductible, where you pay all medical expenses up to a certain amount before insurance starts covering a percentage of the costs. Other plans may utilise a co-pay system, where you pay a set amount for each appointment, and your insurance covers the rest.
It is important to review your specific insurance plan to understand the coverage provided for counselling and therapy services. Your health insurance plan's website should contain detailed information about your coverage and the associated costs. Some plans may require you to choose a therapist within their network, and a list of in-network providers should be available online. However, it is always a good idea to double-check with the therapist to ensure they accept your insurance.
In addition to traditional in-person therapy, some insurance companies are now covering telehealth services for therapy provided by in-network providers. Telehealth therapy can be an excellent option for those who prefer remote services or have difficulty accessing in-person appointments. Online therapy companies' websites typically specify whether they accept insurance, and online therapy directories allow you to search for therapists who accept your insurance and are trained in your specific area of concern.
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Medication
In the US, prescription drugs are covered by a high-deductible health plan. Medicare beneficiaries who meet certain financial qualifications can enrol in an Extra Help program (low-income subsidy), which pays the premium and most of the cost-sharing for the prescription plan. As of 2024, the Inflation Reduction Act has made full Extra Help available to more people. If you are eligible for Medicaid, you automatically qualify for Extra Help. Medicare's Limited Income Newly Eligible Transition (LI NET) provides immediate prescription drug coverage at the pharmacy counter for people with Medicare who qualify for Extra Help but are not yet enrolled in a Medicare drug plan.
If you are uninsured or your health plan does not cover prescription drugs, you may be able to get help in other ways, including discount cards, drug company discounts, and patient assistance programs. Discount cards, such as the Optum Perks discount card, give you access to discounts on both brand-name and generic drugs at participating pharmacies. Drug company coupons help reduce the cost of specific medications. These discounts come directly from the drug manufacturer in the form of coupons or rebates and are usually for brand-name drugs. If you need a prescription that is expensive, check the manufacturer's website for a drug discount plan. Some coupons are only available for use without insurance, while others may cover the copay or coinsurance cost.
When your doctor prescribes you medication, you can check your plan's drug list to see how much it will cost. If it is a higher-tier (and more expensive) drug, you can ask your doctor about a cheaper, lower-tier alternative. You can also ask about generic medications, which are required by the US Food and Drug Administration to work in the same way as their brand-name counterparts but are cheaper. Each time you get a prescription filled, you will pay either a set amount, called a copayment (or copay), or a percentage of the cost.
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Telehealth services
Medicare and Medicaid Coverage
Medicare Part B (Medical Insurance) covers certain telehealth services. After meeting the Part B deductible, patients typically pay 20% of the Medicare-approved amount for their chosen provider's services. This is the same amount that would be paid for in-person services. Medicare will cover telehealth services through December 31, 2024, and this extension applies across the U.S., including at the patient's home.
Medicaid also covers telehealth services, but coverage rules vary by state. For example, online therapy is covered by Medicaid in every state except Iowa. It is important to check with your local Medicaid office or healthcare provider to understand the specific telehealth services covered in your state.
Private Insurance Coverage
Many private insurance plans also provide coverage for telehealth services, but benefits may vary. It is recommended to check with your insurance carrier and provider to understand what copays and fees apply. Some major insurance companies that currently cover telehealth services include:
- Aetna
- Anthem
- Cigna
- Optum
- Tricare
- Traditional Medicare
- Regence
- Carelon
Therapy Platforms
Online therapy platforms such as Talkspace and Amwell also offer their own coverage plans. Talkspace, for example, accepts insurance from many major providers and works with health plans, employee assistance programs, and educational organizations to make online therapy accessible and affordable. Amwell is in-network with insurance companies including Aetna, Anthem, Blue Cross Blue Shield, and UnitedHealthcare.
Cost
The cost of telehealth services depends on the type of care required. Some providers charge a flat fee, while others base their fees on the patient's diagnosis or required testing. Some telehealth providers also offer sliding-scale fees, which are determined by the patient's income or financial circumstances.
In-Person Requirements
It is important to note that some insurance providers may have in-person requirements for telehealth services. For instance, Medicare patients may be required to have an in-person visit annually, unless there is clear documentation outlining why this is not feasible, such as the patient living out of town.
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Frequently asked questions
It depends on your insurance company, state, and healthcare provider. Generally, you can receive coverage for a wide range of services, including counseling, inpatient treatment, and substance use treatment.
Your health insurance plan's website should contain information about your coverage and expected costs. You can also contact your insurance company directly.
Depending on your plan, you may be covered for individual therapy, counseling, inpatient treatment, substance use treatment, and prescription drugs.
Some online therapy companies, like BetterHelp, do not accept insurance. However, many insurers, such as Amwell, now cover telehealth services for in-network providers.
