Mental health and substance abuse treatment is covered under Marketplace 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 individual or family plan must contain comprehensive coverage for the diagnosis, treatment, and rehabilitation of behavioral expenses. Counseling and psychotherapy are also generally included. Substance use disorder treatment is also a covered benefit. Equal rights under the law is guaranteed, and part of our work is to educate and inform consumers about their benefits.
Future legislation under Congress is not expected to remove any key benefits. The opioid epidemic and increase in suicides are being addressed by state and federal legislation, although additional funding is needed. Solutions for low reimbursement rates for out-of-network treatment and behavioral office visits are also being studied. It is possible that 2023 plans will feature more comprehensive benefits for battling addiction, including the waiving of copays, and increasing the number of covered office visits.
Spending limits, and yearly or lifetime dollar limits are not allowed, and this feature will continue. Medicaid Alternative Benefit plans are also required to provide benefits for substance abuse and mental health disorders. Essential Health Benefits must also be provided. Enrollment materials are typically available to help explain specific details. Special Enrollment Periods for pandemics (COVID for example) will continue to be offered, when appropriate. Seniors have a separate OE period.
This includes mental and substance abuse costs. As one of the 10 ESB mandated benefits, all newly-issued Exchange policies must contain these provisions. Grandfathered plans (policies issued before March of 2010), if active, are not required to meet existing government mandates. However, "grandfathered" plans can be canceled at any time by the covered insured, and replaced (during Open Enrollment) with an alternative contract that offers much richer benefits. If Open Enrollment is missed, a special SEP exception may be granted, if certain qualifications are met. A new plan must be selected within 60 days, and federal subsidies will be offered to qualified applicants.
Examples include losing credible coverage from an employer, moving to a different service area, having a baby, becoming ineligible for Medicaid or Medicare, or losing benefits from a divorce or death of a spouse. Typically, up to 60 days following the event is provided to apply for new coverage. No waiting period is applied to any immediate medical conditions. CHIP and Medicaid coverage is offered throughout the entire year. Marketplace plans can be purchased with or without a federal subsidy, and are offered in all states. Plan and carrier availability will vary, and the cost of coverage will also be different, depending where you reside.
Although level of coverage and out-of-pocket expenses will vary by company and area where you reside, common benefits that are often included in private and group plans include ADHD, anxiety, autism, behavior disorders, bi-polar, eating disorder, gender dysphoria, developmental and learning disorder, obsessive-compulsive disorder, personality disorder, psychosis, schizophrenia, sleep-wake disorder, addictive and substance-abuse disorder, and Tourette's disorder. Since depression is the leading cause of disability in the United States, adequate screening and early detection are critical, along withy properly covering generic and non-generic medications.
The Affordable Care Act (ACA)
The ACA (Obamacare), was the signature legislation that greatly improved and enhanced many healthcare benefits about nine years ago. One of the most important changes was eliminating any extra charges, delays, waiting periods, or higher deductibles for pre-existing conditions. Several covered conditions included on newly and recently-issued plans include Panic Disorder, Anorexia Nervosa, Bipolar Disorder, Agoraphobia, and Social Anxiety Disorder. And of course, the new federal tax subsidy was created to reduce rates for many qualified Americans.
This instant tax credit, coupled with the expansion of Medicaid in many states, allows more Americans to receive quality medical benefits regardless of past, present, or future medical issues. Any future legislative changes may alter the amount of the subsidy and its eligibility. But federal funding will continue, and it's likely that the amount of subsidies will slightly increase. Although a "public option" may be introduced in the future, it's unclear if federal subsidies will apply to these types of plans. "Medicare For All" has been discussed but never formally introduced in legislation.
If a subsidy is utilized, premiums are discounted as much as 25%-75%. However, households with higher Federal Poverty Level (FPL) ratios, may actually pay more for their unsubsidized policies than prior to the legislation. Platinum plans without subsidies are the most expensive option. Silver-tier plans eligible for "cost-sharing" will offer lower copays, deductibles, and out-of-pocket expenses. Rates, of course, vary, depending where you live. Plan coverage for physical health services must be equal to mental health and substance abuse services.
While many Midwestern states such as Ohio, Michigan, and Indiana feature moderate pricing, many Northeastern states, such as Connecticut, New Jersey, New York, and Vermont, have very high premiums. Only Delaware offers a single carrier to provide Marketplace plans. Wisconsin, New York, California, Texas, Florida, Ohio, and Washington offer the most carrier choices.
A special SHOP Exchange is offered for small business owners that would like to provide group benefits for their employees. There is no Open Enrollment deadline, and many flexible and customized options can be created. However, often, the number of carriers offering employer-based benefits, is less than the number of carriers that offer individual Marketplace policies. Any employee can "opt out" of group coverage, although they may not be eligible to utilize federal subsidies to reduce their private plan premiums. Behavioral benefits may vary from one state to another.
Private policies must be purchased through designated Open Enrollment periods. For example, for 2022 plans, the period between November 1st and January 15th was the official OE time frame, although a special OE period (February 15-May 15) was previously added. In past years, exceptions and/or extensions have been provided. Previously, a special "grace period" was offered through April 30th for any person that was not covered in the prior year and also paid their non-compliance penalty.
If you miss the deadline, and are forced to purchase a "short-term" plan, many benefits may not be included, such as routine annual physicals, chemical dependency treatment, and cosmetic surgery. Coverage from $100,000 to $2 million is offered by many large carriers, including Blue Cross and UnitedHealthcare. Multiple family members can be included on a single policy, with flexible monthly billing arrangements.
Temporary plans, however, typically exclude mental health coverage, non-generic prescriptions, and physical and mental therapy (inpatient and outpatient). Substance abuse and maternity benefits are also generally not included. Specialist visits often have a copay and deductible to meet although Urgent Care and teledoc visits are typically not subject to the policy deductible. Temporary plans can be kept as long as 36 months in several states. However, in selected states, coverage is offered for less than 12 months.
You can also qualify for a special exception (SEP) if you lose your benefits at work, move to a different location, get divorced, deliver or legally adopt a baby, and several other situations. These "qualifying life events" allow you to receive federal subsidies (if applicable) and purchase a policy at any time of the year. Typically, you are provided 60 days from "the event" to enroll. Other exemptions include substantial income change, getting married, adding or subtracting a dependent, or a change in your disability status. Proof of these qualifying life events (QLE) must be submitted in writing.
Otherwise, short-term and other policy options are not considered compliant, and therefore are not eligible for subsidies or having pre-existing conditions covered. Although they may provide catastrophic/hospital benefits, they generally do not cover depression, schizophrenia, obsessive compulsive disorder (OCD), and other related ailments. Outpatient counseling is also not a covered expense with most temporary plans, and physical and occupational therapy is often excluded. Rehabilitation costs are also generally not reimbursed. Air and ground ambulance transportation expenses may be included, but not 100% covered.
Among the specific provisions that must be included in newly-issued policies are substance abuse (and accompanying disorders), behavioral treatment, counseling, psychotherapy, and several other inpatient-related expenses. Each state has different levels of coverage although annual and lifetime caps can not be placed on benefits. Facility and specialist availability will also vary in different parts of the country. In many rural areas, there also may be much larger travel distance times (perhaps as much as 60-90 minutes) to obtain the specialized assistance that is needed. Although many Medicare products offer travel assistance, typically, under-65 Exchange plans do not.
As bigger carriers, such as Aetna, exit, and then return to the private Marketplace, it is possible that travel times may increase in specific parts of the US. Many states only have one or two carriers underwriting private business, although by 2023, the number of participating carriers may increase. UnitedHealthcare re-entered several states and offers a limited 2022 exchange portfolio. In most states, UHC markets short-term plans through their subsidiary Golden Rule.
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. Extra coinsurance can also no be imposed. This is a significant change from 2013 and earlier, when carriers could routinely exclude coverage or impose large out-of-pocket expenses, before all policy requirements were met. It was also common to exclude many outpatient costs.
NOTE: Temporary plans (earlier discussed), which can be purchased at any time of the year, since they are non-compliant, can legally exclude or limit mental and/or behavioral benefits. And typically, they do! Short-term contracts are not eligible for state or federal subsidies, or tax-credits, and can therefore avoid offering mandated coverage that is required on Marketplace policies. These types of policies are not intended for long-term comprehensive needs, and we do not recommend considering a short-term policy unless you only require catastrophic benefits with higher out-of-pocket expenses.
Temporary plan availability will vary from one state to another. Although 36 months of continuous benefits are offered in several states, some states only allow policies to be renewed after three months, with medical underwriting guidelines that must be met. Short-term health insurance plans are not approved in the following states: New Mexico, Connecticut, Hawaii, Vermont, Colorado, California, New York, Maine, New Jersey, Massachusetts, and Rhode Island.
Mental Health Parity And Addiction Equity Act (MHPAEA)
The Mental Health (MH) Parity And Addiction Equity Act 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. This includes office visits to primary-care physicians (PCP) and specialists.
This federal parity law applies to Federal Employees Health Benefits Plan (FEHBP), employer-funded plans with 50 or more workers, Marketplace and state exchange plans, Medicaid alternative benefit plans, Medicaid managed-care plans, CHIP plans, individual market plans that are non-grandfathered, and and small employer plans that are not grandfathered. Medicare plans, VA plans, and TRICARE plans. Note: Obamacare increased protection under the federal parity law. Qualified health plans (Exchange and off-Exchange) must include SUD as an essential health benefit.
The legislation (courtesy of Paul Wellstone and Pete Domenici) 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. This action must be transparent, and be made available in a timely manner. Discriminatory practices can no longer be utilized, and the legislation applies to both Seniors, and persons under age 65. Originally, the legislation applied only to Group plans, but that feature was amended. Self-funded group health plans and private employment-based plans are regulated by the Department of Labor.
Typically, a request in writing for additional information must receive a response within 14-30 days. If not received, additional actions can be taken. Also, since better employer compliance monitoring has begun, equal cost-sharing and providing easier access to psychiatrists should become more routine, rather than the exception. This is especially helpful to patients that move to a different state and begin to utilize a new specialist.
The law also applies to both private and public sector companies. Both state and federal authorities have enforcement capabilities to ensure parity of coverage. Marketplace plans are required to provide parity between substance abuse and mental health benefits, when compared to surgical and medical benefits. There was also a similar law passed in 1996 which is simply amended by the more recent legislation. These statutes apply to both subsidized and unsubsidized Marketplace plans, so household income does not impact the legislation. Policies that are not subject to ERISA guidelines (non-government contracts) still must meet disclosure requirements.
MHPAEA requirements do not apply to self-insured private employers and non-governmental plans with 50 or fewer employees. Group health plans and certain carriers may be exempt, depending upon the level of costs. Changes made to comply with MHPAEA that result in a cost increase of 2% (or more) may qualify for an exemption. Larger self-funded (government) employers may opt out of requirements, although a HIPAA exemption election must be submitted with approval from CMS. Non-grandfathered ACA plans would not qualify.
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. However, it is possible that workers classified as "part-time" may not be eligible for specific medical plans offered to "full-time" employees. NOTE: Quantitative and non-quantitative treatment limitations have slight variations. Alo, CHIP, Medicare, and Medicaid are not group plans and are not issued by private insurers. Therefore, many of the previously-discussed regulations do not apply.
Some regulations do not apply to smaller employers or policies that are privately purchased. The 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. Also, although Medicaid expansion does not directly impact benefits, with more Americans covered, possible changes may be made between now and 2023, as more states expand Medicaid eligibility requirements. If the Affordable Care Act (ACA) Legislation is ever changed or repealed, additional changes can be expected.
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, there is a recourse. In many instances, decisions are reversed and/or restitution is paid. The process can be long and tedious, but partial or full reimbursement is possible. Wait times can vary, depending upon your state of residency. Documentation should always be kept since additional information may be requested.
The Parity Implementation Coalition (their website is found at 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. Sample appeal letters are available to help expedite any potential claim. Although all provided resources are free, they should not be substituted for proper legal counsel (if needed).
Frequency of office visits is an example of the parity agreement. For example, a medical plan can not offer unlimited primary care physician office visits while limiting visits to a psychologist or psychiatrist. If this occurs, the plan is considered non-compliant with the MHPAEA. Exclusion of inpatient addiction treatment or inpatient substance use disorder treatment violates the Final Rule. The "Final Rule" states that plans can have multi-tiered prescription drugs and tiered networks. Enforcement authority for is primarily handles by states, instead of the federal government.
A resource guide provides valuable advice when insurance and regulatory systems require appeals to unfavorable decisions. Controlling costs is sometimes disadvantageous when cost-containment measures increase consumer out-of-pocket costs.
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. If a parity violation is suspected, a copy of the benefit booklet should be reviewed. A licensed broker can help obtain a copy. The Human Resources department can also provide assistance.
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. Not only are the number of providers slowly decreasing in many areas, but the number of available Marketplace carriers has reduced, as companies such as UnitedHealthcare, Blue Cross, Cigna, and Aetna, limit the number of participating states that they offer plans. Humana has not yet re-entered the private under-65 (ACA) market yet.
By 2023, more companies are expected to offer options in most states, assuming ACA Legislation is substantially updated or individual states are given more control over plan design. Already, UnitedHealthcare, Cigna, and Aetna have re-entered several states, offering both on and off-Exchange plans. Their networks are countrywide and provide comprehensive options to many consumers. Out-of-network benefits are also available.
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. It is also important to check provider-availability each year, since it is not uncommon for doctors and specialists to change carrier affiliations. Urgent Care facilities are often expanded, so up-to-date information is needed.
You may also find that a few psychologists, psychiatrists, marriage and family therapists, licensed professional counselors, and other related specialists do not accept insurance. Therefore, unless you pay in cash, check, debit card, or 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. However, in most areas, both "cash" and "copay" are available, so treatment will be accessible. Your out-of-pocket cost may be reduced as much as 20%-40%.
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. If you own an existing HSA, you can tax-deduct the cost of treatment. HSA plans may require you to initially submit the claim to receive the negotiated cost reductions. Within a few weeks, a negotiated bill will be sent.
However, if you build 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. These resources are constantly updated, so there could be changes from just a few months ago. In some situations, "discount cards" may be accepted, although the typical savings is only about 10%-20%. Generally, you should not pay for these cards. Often, telemarketing companies attempt to sell them online and via email.
Not every plan that is available is ACA-compliant. Actually, many "short-term" policies are very popular, and issued by major reputable companies (or carriers they work with), such as UnitedHealthcare and Blue Cross Blue Shield (BCBS). However, these are considered "off-Exchange" policies and are not required 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. Also, a deductible or coinsurance typically applies to these benefits, which substantially increases your out-of-pocket costs. Inpatient and outpatient group and individual therapy benefits may be limited or excluded.
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. If a scheduled premium is not paid, you may not be able to reinstate the policy, and may be forced to pay for treatment out-of-pocket, until the next Open Enrollment. Although the application process begins in November, the actual effective date is January 1. Rates are typically published in September or October.
Important Note: If you voluntarily terminate a compliant plan, and purchase a short-term policy, you will have to wait until the next Open Enrollment to sign up for a policy that guarantees to cover your pre-existing conditions. This situation often occurs when initially a cheap temporary plan is quite appealing, but then the realization of excluded benefits is realized. "Limited benefit" plans may be available, but they often charge an application fee, and are not considered major medical coverage. Several supplement and and ancillary plans are offered, but large gaps in coverage will likely occur. Often, there is a daily maximum benefit for many in-hospital and surgery expenses.
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. Also, many persons that reach age 65 elect to postpone Medicare benefits because of their work status.
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. Over the last 10-20 years, the quality of outpatient services has markedly increased. The number of available specialists has also risen.
Additional Medicare Benefits
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). Although expensive, these treatments are covered on many plans. Alcohol and drug usage that is considered "inappropriate" is also covered, along with one annual depression screening. This screening, however, must take place in a physician's office or clinic, so additional visits and therapy can be provided, if needed.
An annual mental wellness checkup is covered and highly encouraged to utilize. If assignment is accepted, the visit is free. Within the first year that you become eligible for Part B, an annual welcome preventative visit is covered. Possible depression risk factors are discussed. Medication management and family counseling are also benefits that are very helpful. Often, the counselor or therapist can determine the effectiveness of current treatments, and possible recommended changes.
Partial hospitalization includes psychiatric services (outpatient) that are less costly than an in-hospital stay, but provide more comprehensive treatment than regular physician visits. Treatment is often available through local Community health centers. Education and occupational therapy also may be covered. Transportation expenses from facilities and job skills testing and training must be paid with your own out-of-pocket expenses.
Part D Prescription Drug Benefits
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. Your physician or specialist may be able to adjust your prescription, so it is better covered by your medical coverage.
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. Since included drugs can be added or deleted, it's important to review the list each year. If a drug you are currently taking is deleted, you must receive written correspondence at least 60 days before the change is effective.
Examples of prescription drugs that are typically covered include Fluoxetine, Citalopram, Sertraline, Paroxetine, Escitalopram, Clonazepam, Alprazolam, Lorazepam, Methylphenidate, Amphetamine, Dextroamphetamine, Lisdexamfetamine Dimesylate, Carbamazepine, Lamotrigine, and Oxcarbazepine.
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. Regardless if your state has a federal or state-run Marketplace, many of your expenses are guaranteed to be covered, even if you had no prior coverage when you enrolled. A "coverage determination" can be requested if you feel a specific drug should be approved, a drug is more costly than you feel is fair, or prior authorization is required before you have access to a medication.
The federal legislation regarding parity between physical and mental illness has made great progress, but as Open Enrollment has just ended, there are still many inequalities regarding treatment. One of the biggest impediments that still exists is the limitation of visits that is often found when utilizing a psychiatrist, but not a chiropractor.
The Johns Hopkins School Of Public Health studied benefits from the initial Open Enrollment period, and concluded that required out-of-pocket expenses were higher for mental treatment, and often required additional layers of required approval. However, plans issued in 2015 should alleviate some of the unfairness.
How much should employers know about their worker's mental health? With the Germanwings Airlines tragedy from a few years ago, and the possible impact of the co-pilot's depression on the deliberate crash into the French Alps, the topic of workplace privacy is being widely discussed. If the release of personal information saves future lives, perhaps exceptions should be made.
Andreas Lubitz (the co-pilot) had suicidal tendencies and had battled depression in the past. Although he was legally approved to perform his co-pilot duties, would his employer have acted differently if presented with more information? Currently, this is a very controversial topic, even though the crash occurred a few years ago.