Mental health treatment is now covered under most conventional health insurance plans, and is also considered an "essential benefit" (ESB) on any policy purchased through a Federal or State Exchange. This means that a typical Marketplace plan must include comprehensive coverage for the diagnosis, treatment and rehabilitation of behavioral expenses. This includes mental and substance abuse costs. As one of the 10 ESB mandated benefits, all newly-issued policies must contain these provisions.
The Affordable Care Act (ACA)
The ACA (Obamacare) was the signature legislation that greatly improved and enhanced many healthcare benefits. One of the most important changes was eliminating any extra charges, delays or higher deductibles for pre-existing conditions. And of course, the new federal tax subsidy was created to reduce rates for many qualified Americans.
Pre-existing conditions can not be excluded on any newly-issued plan that is Affordable Care Act-compliant. This feature also applies for any person that purchases a policy that was not previously covered, or had a lapse in coverage. There is no waiting period, surcharge or limitation of benefits for any of your expenses.
However, policies must be purchased through designated Open Enrollment periods. For example, for 2015 plans, the period between November 15th and February 15th (2015) is the official OE time frame. You can also qualify for a special exception (SEP) if you lose your benefits at work, move to a different location, get divorced and several other situations.
Among the specific provisions that must be included in newly-issued policies are substance abuse (and accompanying disorders), behavioral treatment, counseling, psychotherapy, and some other inpatient-related expenses. Each state will have different levels of coverage although annual and lifetime caps can not be placed on benefits.
Any restrictions listed on the general policy can not single out a specific type of illness. This includes copays, coinsurance and deductibles. For instance, if the copay for a non-preventive office visit is $25, a mental-illness visit can not be singled out with a copay of $35 or $50. Also, the number of covered visits can not vary from one type of illness to another.
Parity And Addiction Equity Act Of 2008 (MHPAEA)
The Mental Health (MH) Parity And Addiction Equity Act Of 2008 has now become fully implemented. It states that there should be no difference in copays, coinsurance and deductibles between medical and surgical benefits and other "mh" and substance abuse and use disorder (SUD)benefits. The level of treatment including the quality, scope and its duration must also not differ from other types of treatment.
The legislation also mandates that if out-of-network benefits are offered for hospital and surgery expenses, the same must be provided for MH and SUD coverage. If treatment (or payment for treatment that was performed) is denied, then the reason for that action must be made available to the beneficiary or participant.
The law applies to both private and public sector companies. Both state and federal authorities have enforcement capabilities to ensure parity of coverage. There was also a similar law passed in 1996 which is simply amended by the more recent legislation.
The IRS, Department of Labor and Department of Health and Human Resources are all involved in compliance. Each state insurance commission also has jurisdiction in many circumstances. These regulations apply to plans provided by employers with more than 50 employees.
It does not apply to smaller employers or policies that are privately purchased. This MHPAEA fact sheet provides additional more detailed information. Also, the impact on Medicaid and Medicare is a bit murky, since additional rulings and regulations are expected to provide more specific guidelines.
If you submit a claim that is denied, or you feel that your current coverage is unfairly imposing restrictions on benefits you feel should be covered, you do have recourse. In many instances, decisions are reversed and/or restitution is paid.
The Parity Implementation Coalition (their website is found here) specializes in legal compliance in the mental health field. They handle complaints from both providers and patients, and assist in mediating or solving your concerns. For more than 15 years, they have helped fight mental illness and substance abuse discrimination against families and individuals.
If your coverage is self-administered by your employer, then the federal government may have to handle your complaint or appeal. However, the Coalition may still be able to offer guidance regarding which resources will be the most helpful and how to initiate the appeal process.
Provider Network Availability
Perhaps one of the most critical components of your coverage is the availability of network providers from your individual or group plan. Although most large carriers have a significant number of physicians, specialists and medical facilities within a short radius of most customers, finding mental health professionals may be a bit trickier.
It's imperative that you check the number of providers that are within a reasonable driving distance. If the closest provider is an hour away, you may not want to drive that distance. Or, you can compare multiple companies and their provider networks, and select the one that is able to provide the closest MH or SUD provider. Even the cheapest available HSA plans will allow you to utilize large networks of specialists and benefit by the negotiated discounts.
You may also find that many psychologists, psychiatrists and other related specialists do not accept insurance. Therefore, unless you pay in cash, check, or debit,credit card, immediate service may not be available. This practice is an effort to reduce cost (including administrative staff salaries) and the time and labor hours often needed when attempting to recover patient reimbursement.
The Journal Of The American Medical Association (JAMA) also recently revealed that only about 50% of practicing psychiatrists accepted individual or group health insurance coverage. If you need this type of treatment and you do not want to pay out-of-pocket for your services, it's critical to find a professional in your area. There are reputable rating websites (such as YELP) that will help you find professionals that have been recommended by other consumers.
"Cash only" providers often charge less (up to 50%) than a typical provider-affiliated physician. However, you will have to pay for your treatment either before or just after your appointment, and typically balances must be paid in full. Billing statements are not mailed since they are collected in person.
However, if you build up a long-term relationship with a physician, alternative billing arrangements may be able to be arranged. There are also provider service locators that can help you find a list of specialists in your area that may be willing to accept new patients.
Not every plan that is available is ACA-compliant. In fact, many "short-term" policies are very popular, and issued by major reputable companies, such as UnitedHealthcare and Blue Cross Blue Shield (BCBS). However, these are considered "off-Exchange" policies and do not have to conform to specific legislative mandates. Typically, temporary contracts have very limited mental-illness coverage, since coverage is kept for less than 12 months, and often less than six months.
However, these types of policies will help you maintain major medical benefits until you become eligible for an SEP (mentioned earlier) or the next Open Enrollment. Once your Marketplace policy is effective, you may resume coverage for your specific needs. Naturally, you should still continue treatment, if possible, for any conditions you have, despite your existing healthcare plan not covering them.
Mental Health Benefits Through Medicare
Once you reach age 65, your medical benefits will be covered through Medicare. Your prior or employer-sponsored retiree plan will be canceled since you can not carry primary and Medicare benefits together. Of course, if you are still working, you can keep an existing group coverage, if available.
Part A covers your inpatient expenses including nurses, room charges, meals and other related expenses. Benefits would be payed for stays in a conventional hospital as well as a psychiatric hospital. However, there is a 190-day limit (lifetime) for psychiatric hospital expenses. Phones, televisions and a private room are not covered. A deductible applies to inpatient care and after the first 60 days, out-of-pocket coinsurance will apply.
Part B includes coverage for visits to the following professionals: (Assignment must be accepted and these services may not be covered at 100% as copays and/or coinsurance may apply). Usually, there is a 20% coinsurance for specific treatment.
Clinical social worker
Drug and alcohol counselor
Many outpatient services are also covered that don't take place in the traditional hospital setting. Examples include offices used by doctors, clinics and therapists. Also, many hospitals have outpatient services that treat alcohol and drug use. A depression screening (one per year) is also allowed.
Additional Part B benefits include single and group psychotherapy with physicians and other approved licensed specialists. If family counseling is part of the recommended treatment, it also is covered. Occasionally, mediation services or management will be required along with diagnostic tests and injection drugs (that you can not give to yourself).
Part D is the prescription portion of your Medicare coverage. Prior to enrolling in a Part D plan, it is important to determine if your medications are part of the "formulary" listing. This list is always available from the company that issues the policy. There's no guarantee that all of your prescriptions will be covered, although most are likely to be on the list.
However, some of the types of drugs that are normally required to be included in benefits are anticonvulsant, antidepressant, and antipsychotic medications. A "cover determination" can be requested if a specific prescription is not on the formulary list and you feel it is needed or it's too expensive for you to afford to pay.
Treatment for mental illnesses including depression have become much more comprehensive and affordable in recent years. There are many available health insurance plans that include these benefits at a cost you can afford.