As reported on HealthCare.gov, mental health and substance abuse services are covered as significant benefits under all Marketplace plans. These plans are required to provide "parity" protection between medical and surgical benefits and benefits of mental health and substance abuse. What this generally means is that the boundaries cannot be more restrictive for one than the other. This parity applies to:
- Financial limits, such as repayments, deductibles, coin insurance and exclusive limits.
- Treatment limits, such as the number of visits or days covered.
- Care management, such as approval requirements before treatment is provided.
Although there are physical health conditions that can be established with concrete medical evidence, diagnoses of mental health conditions are much more subjective, as they are based on opinions from mental health professionals and science that are lacking in physical evidence.
Are existing conditions covered?
A health plan on the market can not deny you coverage or charge you more for health insurance because you have a previous condition. This rule also applies to mental states and substance abuse. In addition, these plans prohibit placing an annual or lifetime dollar limit on any coverage that is considered a material benefit. According to current law, this includes mental disorders and substance abuse disorders.
Which mental health services are considered to be significant health benefits?
Federal law requires all market plans to cover:
- Psychotherapy, counseling and other behavioral health care [1
- Behavioral health and mental inpatient services
What about private health plans?
Private health plans can vary in their mental health benefits. They usually offer fewer mental health services than Medicaid or public mental health programs. Many cover:
- Medical care in outpatient care
- Emergency care
- Prescription drugs
- Hospital care
Does Medicare Mental Health Services cover?
Medicare covers a variety of mental health services, as follows:
- Part A: This is the hospital insurance section of Medicare. It covers psychiatric care within patients, including a hospital room, meals, nursing and supplies and services.
- Part B: Medicare Part B is medical insurance. It covers mental health services received outside a hospital, such as doctor's appointments, laboratory tests and visits to clinical psychologists or social workers.
- Part D: This is the prescription drug portion of Medicare. It covers medications 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 registered with a Medicare Advantage HMO, PPO or other health plan, check the member material for information on the plan's mental health benefits.
What mental health treatment does Medicaid cover?
Medicaid programs may vary from state to state. All programs provide certain mental health services, which may include counseling, medication management, therapy, peer support, social workers, and drug abuse. Coverage for new adult Medicaid expansion populations must include significant health benefits, which have been established to include mental health and substance abuse. It must meet the same parity requirements as health plans in the market.
If you are not sure what mental health services your health plan should provide, talk to our knowledgeable agent. We can review registration or other material for your plan to help you find out the coverage levels for different services.