One of the many landmark provisions of the Affordable Care Act was its emphasis on covering mental and behavioral health...
One of the many landmark provisions of the Affordable Care Act was its emphasis on covering mental and behavioral health issues. Before the ACA, such coverage was sporadic and inconsistent. While some health insurance plans offered mental health care, many plans had no coverage at all.
The Importance of Mental Health Insurance
Mental and behavioral health problems are widespread and serious. According to the National Alliance on Mental Illness, its most recent numbers show:
-- 22.8% of U.S. adults, or roughly 1 in 5, experienced mental illness in 2021 (57.8 million people).
-- 5.5% of U.S. adults experienced serious mental illness in 2021 2018 (14.1 million people).
-- 16.5% of U.S. youth ages 6 to 17 experienced a mental health disorder in 2016 (7.7 million people).
-- 7.6% of U.S. adults experienced both a substance use disorder and mental illness in 2021 (19.4 million people).
Over the last several years, those numbers have been climbing. The good news is that, thanks to the ACA, far more people have health insurance to help pay for mental health treatment. Mental health insurance coverage is crucial because it makes mental health care more accessible and affordable, reducing financial barriers to accessing treatment. It also helps normalize seeking help and can lead to better overall health outcomes, both physical and mental. Yet many people still lack coverage.
According to NAMI:
-- 10.6% of U.S. adults with mental illness had no insurance coverage in 2021
-- 11.9% of U.S. adults with serious mental illness had no insurance coverage in 2021
When it's time to shop for health insurance, here's what you should know about mental and behavioral health insurance coverage.
[READ: What to Do During a Mental Health Crisis]
Mental Health Benefits: Requirements of Coverage
As of the ACA enactment in 2014, most individual and small group health insurance plans, including plans sold on the Marketplace, are required to cover mental health and substance use disorder services.
According to the U.S. Department of Health and Human Services, mental and behavioral health services are considered essential health benefits, which means that most individuals and small employer health insurance plans must provide coverage for them. This includes any plan offered on the Health Insurance Marketplace.
As an essential health benefit, mental and behavioral health services must cover:
-- Behavioral health treatment, such as psychotherapy and counseling
-- Mental and behavioral health inpatient hospital services
-- Substance use disorder (also known as substance abuse) treatment
-- Preexisting mental and behavioral health conditions
In addition, health insurance plans must comply with mental health and substance use parity requirements, meaning coverage for these services generally cannot be more restrictive than coverage for medical and surgical services.
Each state's Medicaid program covers some mental health and substance use services, though coverage can vary by state. According to Medicaid.gov, The Children's Health Insurance Program provides comprehensive mental and behavioral health coverage to diagnose and treat a diverse range of mental health conditions and substance use disorders.
Medicare also covers many mental health services:
-- Medicare Part A (hospital insurance) covers inpatient mental health care services, including your room, meals, nursing care and other services and supplies.
-- Medicare Part B (medical insurance) covers mental health services outside of a hospital, including visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker and lab tests.
-- Medicare Part D (prescription drug coverage) covers drugs that treat a mental health condition. However, each Part D plan has its own list of covered drugs, called a formulary, so not all plans cover the same medications.
Most employer-based coverage is required to comply with ACA requirements regarding mental and behavioral health, including parity protection. The Department of Health and Human Services recommends that you look carefully at your plan's enrollment materials to understand your coverage. The ACA requires insurers to provide easy-to-understand summaries of benefits, including mental health benefits.
If you don't get insurance through an employer or Medicare, HHS recommends you learn about health insurance coverage provided by Medicaid, CHIP or the health insurance marketplaces by visiting HealthCare.gov.
The health insurance marketplace, created by the federal and state governments to make buying health coverage easier and more affordable, lets you compare health plans, find out if you are eligible for tax credits to help pay for private insurance or health programs like CHIP and enroll in a health plan that meets your coverage and financial needs. All these plans must comply with ACA regulations on mental and behavioral health coverage.
Military Veterans
TRICARE and VA Health Care, the federal health insurance plans for people who have served in the military, cover mental and behavioral health. According to NAMI, military veterans may also qualify for enhanced eligibility for VA Health Benefits, which means they do not have to pay co-pays for conditions potentially related to their combat service, including mental health issues like PTSD, depression, suicidality and substance abuse.
[READ: Mental Health Resources for Seniors]
What to Consider When Shopping for Mental Health Coverage
When shopping for mental health coverage, there are a few important things you should consider.
Check the network and formulary
If you're already working with doctors and taking medicine, you obviously want to make sure that a new insurance plan will allow you to continue your treatment. If you're looking for a new plan and intend to get treatment, you'll want to make sure your insurance has a wide range of options for you.
"Confirm that the selected plan offers a diverse panel of in-network therapists, psychologists and psychiatrists, especially in your local area," says Sarah Bolor, a licensed clinical social worker and clinical director at SayIt Mental Health, a practice in Las Vegas. She also says that you may want to look at options for out-of-network coverage and research how much it would cost to see a specialist.
Review the number of covered sessions
After all, if you have some serious issues you're dealing with, it probably won't do you much good if your insurance only pays for four visits to a psychiatrist.
"I highly encourage that a client selects a plan that offers unlimited sessions per calendar year," Bolor says.
Read the fine print
Bolor also suggests confirming the cost of the co-pay and deductible. It won't do you much good if your health plan covers mental health, but it's still expensive enough that quality care is cost-prohibitive.
She also suggests you ask if prior authorization is required before beginning services.
"This can add a delay and become a complex process. It isn't ideal for someone who is experiencing a mental health crisis," Bolor says.
You'll want to avoid short-term health plans, which may be dirt cheap, but as a general rule, are not regulated by the ACA and often don't cover mental and behavioral health care.
Consider telehealth options
Bolor says that virtual therapy is becoming more common and offers a lot of convenience. Not everyone can get away from work or their home for regular in-person therapy visits, but you can probably make time on your laptop or phone.
Inquire about an employee assistance program at work
If your health plan is lacking when it comes to treating mental health, your company may offer a confidential program to provide free mental health counseling. Check your employee handbook or contact a human resource specialist for more information.
Be patient
Knowing that it may take a while to find a good health insurance plan that covers mental health can help keep you from getting discouraged when you hit roadblocks.
"Finding affordable, yet quality coverage can be difficult," Bolor says. She recommends you ask a lot of questions to get the answers you need.