Before the Affordable Care Act was implemented, private health plans sold on the health insurance marketplace did not typically cover mental health services; now however, most of them do.
The Affordable Care Act’s (ACA) parity rules mandate that if your health plan offers therapy services, they must do so at an equivalent level as other health benefits. However, coverage varies widely among plans.
Medicare
Medicare provides extensive mental health coverage, from depression screenings and counseling sessions to inpatient hospital stays and outpatient treatments. Most beneficiaries can access these services either through Medicare Part A – inpatient psychiatric hospital stays – or Part B, outpatient treatments; Medicare Advantage plans also often offer mental health coverage; however they may differ from traditional Medicare benefits structures by imposing cost sharing for out-of-network mental health services – typically copays or coinsurance costs (although some plans did not require any).
Medicare is a federal health insurance program for people 65 and over and certain disabled individuals, providing mental health coverage through Parts A and B. Traditional Medicare or a Medicare Advantage plan with both Part A and Part B eligibility qualifies for mental health benefits; however, to access them they must first pay an initial deductible plus 20% of Medicare-approved fee for outpatient services (i.e. visits to psychiatrists, psychologists or any qualified mental health provider who accept Medicare assignment). To locate providers nearby use the Centers for Medicare and Medicaid Services online tool which will search providers’ locations near them – simply enter your zip code into it to search.
Medicare Part A covers inpatient mental health services up to 190 days at any given time in an inpatient psychiatric hospital, though Medigap or Medicare Advantage plans may offer additional coverage; please see their individual rules and costs for further stays.
Medication coverage is another aspect of Medicare’s mental health coverage, with most Parts D plans required to cover antidepressants, antipsychotics and various other mental health medications; specific coverage may differ based on plan.
Psychologists are less likely than other specialists to accept Medicare patients as new patients; according to KFF analysis, only 60% of psychiatrists report accepting new Medicare patients; this number is considerably lower than general practitioners or family medicine physicians (81%). Reasons may include low reimbursement rates, lengthy wait times, and preference for private health plans over Medicare. CMS has taken steps to overcome some of these barriers by expanding Medicare Advantage’s network adequacy rules to include psychiatrists and clinical social workers, expanding telehealth services for mental health treatment purposes, and mandating plans notify enrollees when their psychiatrist opts out of Medicare coverage.
Medicaid
Medicaid is a government-sponsored health insurance program designed to cover people living on low incomes. While federal guidelines govern this coverage, each state manages their own program which means eligibility and services may differ between states.
There is a ray of hope: Most states cover some form of mental health care more effectively than private insurers do. Each state usually has a publicly funded network of outpatient mental health providers who accept Medicaid; they often offer therapy such as group and individual counseling, depending on your provider directory; if your state does not have one specifically dedicated to accepting Medicaid services in your area.
Many Medicaid plans cover medication-assisted treatment (MAT). MAT involves the combination of FDA-approved medications with behavioral therapies like motivational interviewing or cognitive behavior therapy to provide effective therapy solutions. Studies have revealed this approach can often outperform taking just medication alone. At present, common MAT medications include methadone, buprenorphine and naltrexone.
As part of their mental healthcare coverage, most Medicaid programs also cover integrated care services that integrate behavioral and physical healthcare services together, including mental health screenings in primary care settings, psychiatric evaluation combined with medical services, case management integration services and integration of case management. These integrated care services tend to be covered more often than other forms of mental healthcare services; more than half of states don’t even require copays for them!
Medicaid covers institutional care and intensive services for those in need. This may include hospital visits, 24-hour observation and residential treatment programs – usually reserved for individuals requiring higher levels of assistance to manage their symptoms without assistance.
Note that Medicaid claims may not always reflect reality when assessing mental illness in a population, particularly when estimating its prevalence. Emergency room visits related to mental health conditions have been shown to differ widely across states and counties due to differences in how mental illness conditions are coded and submitted as well as regional variance in quality data on Medicaid claims submission.
Private Insurance
Private plans purchased on the individual market provide another source of coverage for mental health needs, with different levels of coverage depending on each policy term. While such plans often come with expensive monthly premiums, it’s essential that individuals carefully consider any benefits from investing in mental health coverage against its associated costs.
Dependent upon the plan type and individual provider, whether or not private insurance covers therapy depends on a number of variables. Companies often offer several plans with various coverage features for mental health needs; it’s essential that individuals research all available plans to understand if any are applicable for therapy coverage. Some plans, like HMO or PPO plans require individuals visit a primary care physician prior to being referred for mental health professionals while other may not require this step at all. In addition, some insurances offer telehealth mental health services which allow those with busy schedules stay connected with their therapist.
Though progress has been made over time, accessing mental health coverage remains an issue for many Americans. While legislation like the Affordable Care Act and Mental Health Parity and Addiction Equity Act makes obtaining coverage easier for many, its premium cost may still be prohibitive if individuals face financial difficulty.
Medicaid programs may provide relief for those unable to afford insurance premiums, including mental health treatments that are deemed essential health benefits. While specific programs vary between nations, all must give individuals access to mental health treatment deemed an essential health benefit. Depending on which plan a person enrolls in, there may be restrictions placed upon how often or long a therapist visit(s), or in some instances they will need hospitalization for mental health purposes.
Individuals without access to private or employer-sponsored health insurance may still find help for their mental health needs from local community organizations, churches and private charities. Many of these groups offer sliding scale fees for those without insurance – providing an inexpensive alternative to more costly therapy sessions.
Public Insurance
Mental health had long been excluded from health insurance plans. Since the implementation of MHCA 2017, however, people suffering from mental illness now have access to medical treatment, including psychiatric services. Furthermore, this law has helped decrease stigma surrounding mental illness; but many barriers still exist despite its introduction.
First among these obstacles is limited access to health care professionals and finding health insurance coverage for mental health conditions; due to both of these constraints, many do not receive necessary treatment.
In the US, most individuals receiving health care services do so through public insurance programs like Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). These plans typically offer lower costs for therapy as well as access to various kinds of therapies; additionally they usually feature in-network providers who result in reduced out-of-pocket expenses when visiting these professionals.
Yet, many who possess these forms of insurance still face financial barriers to getting the treatment they require. One recent study discovered that over half of respondents who had either public or private health insurance reported cost as being an impediment to receiving care; this figure suggests further reforming of our current health system to provide easier access to health services for those who require it.
The Affordable Care Act and Mental Health Parity and Addiction Equity Act both seek to address these concerns. Both laws prohibit insurance companies from providing less generous benefits for mental health than physical health, prohibit quantitative limits being set on inpatient or outpatient services and count any copays paid towards annual deductibles.
Additionally, laws have made it illegal for insurers to discriminate against people living with mental illness by charging higher premiums or restricting networks for accessing these services. Unfortunately, however, these laws have yet to effectively eliminate barriers preventing too many Americans from receiving necessary treatment.
