Types of Mental Health Services Typically Covered by Health Insurance Plans

Posted: July 12, 2023

In the United States in 2023, most adults with mental illness had insurance coverage, but only about half received treatment. For some, a significant barrier was their insurance provider’s coverage of mental health services. Even if your plan covers mental health services — and most of them do — health insurance can be confusing. You might not know which services your plan covers, how much you’ll pay out of pocket or which providers you can visit.

Questions like these will significantly affect your or your loved one’s ability to get treatment, so we’ve put together a guide to mental health insurance coverage.

Are Mental Health Services Covered by Insurance?

As with many questions related to health insurance, the answer is that it depends. Coverage for mental health services is optional for some plans and required for others, but many of today’s providers offer it.

While every plan is a little different, here’s what the law says about the requirements for various insurance plans to cover mental health services.

• Employer-sponsored plans: Employers with 50 or more employees must offer health insurance, but not necessarily plans that include mental health services. Still, many companies provide some form of mental health services and support to improve employee retention.
• Marketplace plans: All plans from the Marketplace, including federal and state-managed plans, must cover mental health and substance use disorder services. These services are part of the 10 essential benefits that Marketplace plans must cover. Benefits include behavioral health treatments, substance use disorder treatment and mental and behavioral health inpatient services. These plans cannot put a dollar limit on your coverage or deny coverage for existing conditions.
• Children’s Health Insurance Program plans: CHIP programs can vary from state to state, but most provide a wide selection of mental health services.
• Medicaid: All state-run plans must cover the 10 essential health benefits, but the specifics can vary by state.
• Medicare: Medicare plans can be tricky, but they cover mental health services. Medicare Part B covers outpatient services, while Medicare Part A covers inpatient services, with a maximum of 190 days in a psychiatric hospital over the beneficiary’s lifetime. After that, you would need to receive care in a general hospital to get coverage. Other limits may be in place, but Medicare Advantage can help fill in the gaps and improve your coverage.

All these plans must abide by requirements from the mental health parity law, which we’ll discuss later. The Affordable Care Act also prevents these plans from denying coverage or charging you more due to an existing condition. Mental health care also receives several protections from other pieces of legislation, like the Health Insurance Portability and Accountability Act.

Which Mental Health Services Does Health Insurance Cover?

While every insurance plan is a little different, some types of mental health services covered by insurance include:

• Inpatient hospitalization in general hospitals or psychiatric facilities
• Outpatient mental health treatment, including psychotherapy and counseling
• Emergency psychiatric care
• Prescription drugs
• Substance use disorder treatment

Plans will generally only cover these services if deemed medically necessary, so you may need to obtain pre-authorization. Sometimes, your plan might cap the number of treatments or dollar amount spent. Your provider would need to contact the plan provider and argue that further care is still necessary.

Like non-mental health coverage, you may need to meet a deductible before your plan will cover services.

What Is the Mental Health Parity Law?

The Mental Health Parity and Addiction Equity Act, also known as the mental health parity law, requires health plans to deliver similar mental and physical health benefits in a similar fashion to physical health benefits. Plans do not have to offer mental health services, but if they do, they cannot offer those services with more restrictions or higher costs than other benefits.

Before the MHPAEA, many plans that offered mental health services would have restrictive qualifications, higher copays or separate, higher deductibles for those benefits. Now, all services fall under the same deductible, and copays and coinsurance amounts must be comparable. For example, if you pay a $25 copay for most office visits, your plan can’t charge you a $50 copay to see a psychiatrist. Both copays would need to be similar.

The mental health parity law doesn’t apply to plans for small businesses with fewer than 50 employees.

How to Find Mental Health Services Covered by Insurance

Even if your plan covers most mental health services, you’ll need to check on your coverage for specific providers. Ideally, you can find an in-network provider, which gives you lower copays or coinsurance amounts. An in-network provider is also beneficial because they typically submit claims directly to your insurance provider, rather than making you do it yourself. Some plans provide coverage for out-of-network providers, but your out-of-pocket costs might be higher and you may need to submit claims yourself.

Follow these steps to find covered mental health services under your insurance plan.

1. Check Your Insurance Plan’s Directory

Most insurance plans have a directory of in-network providers available to the public. Typically, you can access these lists via the plan provider’s app or website. Head there and look for a tool that says something like “Find a Provider.” These directories should give you a list of in-network clinicians who accept your plan.

Be careful with this list, as the information might be outdated. For extra assurance, or if your provider doesn’t have an online tool, you can always call the company or your provider directly. You can also ask your provider to confirm coverage for specific services. Still, an online directory is a great place to start.

2. Confirm Your Coverage With Your Provider

Always double-check coverage before you receive any services. Not all providers check this information beforehand, so stop and ask before your appointment whether the provider is in-network with your plan.

3. Understand Your Out-of-Pocket Costs

Lastly, check insurance documentation like your explanation of benefits to see your out-of-pocket costs. Remember, your copay or coinsurance amount may not apply until you reach your deductible. If you haven’t paid out your deductible yet, you might owe the entire cost of the appointment.

If you’re unsure what your out-of-pocket costs are or you want extra assurance, you can always call your insurance company to confirm.

Get the Right Coverage When Selecting Your Next Plan

Choosing an insurance plan can be challenging. If you’re concerned about your mental health coverage, take some time to learn which services potential plans cover or work with a professional. An experienced insurance broker can walk you through your options and find the best plan for your unique needs.

If you’re in California, the friendly team at the Health for California Insurance Center is ready to help. We offer a quick, easy-to-use online application and have knowledgeable agents to find you the right plan. Shop California health insurance plans online today, or reach out to us with any questions!