As reported on HealthCare.gov, mental health and substance abuse services are covered as essential benefits under all Marketplace plans. These plans are required to provide “parity” protections between medical and surgical benefits and mental health and substance abuse benefits. What this means, generally, is that the limits cannot be more restrictive for one than the other. This parity applies to:
- Financial limits, such as copayments, deductibles, coinsurance, and out-of-pocket limits.
- Treatment limits, such as the number of visits or days covered.
- Care management, such as authorization requirements before treatment is provided.
While the existence of physical health conditions can be established with concrete medical evidence, diagnoses of mental health conditions are much more subjective, based as they are on the opinions of mental healthcare professionals and science lacking in physical proof.
Are Pre-Existing Conditions Covered?
A Marketplace health plan cannot deny you coverage or charge you more for health insurance because you have a pre-existing condition. This rule also applies to mental conditions and substance abuse. In addition, these plans are prohibited from placing an annual or lifetime dollar limit on any coverage that is considered to be an essential benefit. Under current law, this includes mental and substance abuse disorders.
What Mental Health Services Are Considered Essential Health Benefits?
Federal law requires all Marketplace plans to cover:
- Psychotherapy, counseling, and other behavioral health treatment
- Substance abuse treatment
- Behavioral health and mental inpatient services
What About Private Health Plans?
Private health plans can vary in their mental health benefits. They typically offer fewer mental health services than Medicaid or public mental health programs. Many cover:
- Outpatient mental health treatment
- Emergency care
- Prescription drugs
- Inpatient hospitalization
Does Medicare Cover Mental Health Services?
Medicare covers a variety of mental health services, as follows:
- Part A: This is the hospital insurance portion of Medicare. It covers inpatient mental health care, including a hospital room, meals, nursing care, and supplies and services.
- Part B: Medicare Part B is medical insurance. It covers mental health services received outside of a hospital, such as doctor’s appointments, lab tests, and visits with clinical psychologists or social workers.
- Part D: This is the prescription drug portion of Medicare. It covers drugs prescribed to treat a mental health condition. Each Part D plan has its own list of covered drugs.
Many people receive Medicare benefits through a Medicare Advantage Plan. If you are enrolled in a Medicare Advantage HMO, PPO, or another health plan, check the membership materials for details about the plan’s mental health benefits.
What Mental Health Treatment Does Medicaid Cover?
Medicaid programs may vary from state to state. All programs provide some mental health services, which may include counseling, medication management, therapy, peer support, social worker services, and substance abuse treatment. Coverage for new Medicaid adult expansion populations must include essential health benefits, which have been determined to include mental health and substance abuse treatment. It must meet the same parity requirements as health plans in the Marketplace.
If you are unsure about what mental health services your health plan should provide, speak with our knowledgeable agent. We can review enrollment or other materials for your plan to help you find out about the coverage levels for various services.
