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Do you have Insurance Questions about Mental Health or Addiction Services?

Help is available, if you have:

• Been denied coverage
• Reached a limit on your plan (such as copayments, deductibles, yearly visits, etc.)
• Have an overly large copay or deductible

You may be protected by Mental Health and Substance Use Disorder Coverage Parity laws require most health plans to apply similar rules to mental health benefits as they do for medical/surgical benefits. Select your insurance type below for more about the protections that apply for you, and to get assistance information. There are Federal and State Agencies who can provide assistance.

Q: Does the Affordable Care Act require insurance plans to cover mental health benefits?

Answer: As of 2014, most individual and small group health insurance plans, including plans sold on the Marketplace are required to cover mental health and substance use disorder services. Medicaid Alternative Benefit Plans also must cover mental health and substance use disorder services. These plans must have coverage of essential health benefits, which include 10 categories of benefits as defined under the health care law. One of those categories is mental health and substance use disorder services. Another is rehabilitative and habilitative services. Additionally, these plans must comply with mental health and substance use parity requirements, as set forth in MHPAEA, meaning coverage for mental health and substance abuse services generally cannot be more restrictive than coverage for medical and surgical services.

Q: How do I find out if my health insurance plan is supposed to be covering mental health or substance use disorder services in parity with medical and surgical benefits? What do I do if I think my plan is not meeting parity requirements?

Answer: In general, for those in large employer plans, if mental health or substance use disorder services are offered, they are subject to the parity protections required under MHPAEA. And, as of 2014, for most small employer and individual plans, mental health and substance use disorder services must meet MHPAEA requirements.

If you have questions about your insurance plan, we recommend you first look at your plan’s enrollment materials, or any other information you have on the plan, to see what the coverage levels are for all benefits. Because of the Affordable Care Act, health insurers are required to provide you with an easy-to-understand summary about your benefits including mental health benefits, which should make it easier to see what your coverage is. More information also may be available via the Mental Health and Addiction Insurance Help consumer portal prototype and with your state Consumer Assistance Program (CAP). Additional, helpful information on what you can do to better understand the parity protections you have is available in Know your Rights: Parity for Mental Health and Substance Use Disorder Benefits.

Q: Does Medicaid cover mental health or substance use disorder services?

Answer: All state Medicaid programs provide some mental health services and some offer substance use disorder services to beneficiaries, and Children’s Health Insurance Program (CHIP) beneficiaries receive a full service array. These services often include counseling, therapy, medication management, social work services, peer supports, and substance use disorder treatment. While states determine which of these services to cover for adults, Medicaid and CHIP requires that children enrolled in Medicaid receive a wide range of medically necessary services, including mental health services. In addition, coverage for the new Medicaid adult expansion populations is required to include essential health benefits, including mental health and substance use disorder benefits, and must meet mental health and substance abuse parity requirements under MHPAEA in the same manner as health plans. For additional information on Medicaid and mental health and substance use disorder services, visit https://www.medicaid.gov/medicaid/benefits/bhs/index.html. 

Q: Does Medicare cover mental health or substance use disorder services?

Answer: Yes, Medicare covers a wide range of mental health services.

Medicare Part A (Hospital Insurance) covers inpatient mental health care services you get in a hospital. Part A covers your room, meals, nursing care, and other related services and supplies.

Medicare Part B (Medical Insurance) helps cover mental health services that you would generally get outside of a hospital, including visits with a psychiatrist or other doctor, visits with a clinical psychologist or clinical social worker, and lab tests ordered by your doctor.

Medicare Part D (Prescription Drug ) helps cover drugs you may need to treat a mental health condition. Each Part D plan has its own list of covered drugs, known as formulary. Learn more about which plans cover various drugs.

If you get your Medicare benefits through a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, check your plan’s membership materials or call the plan for details about how to get your mental health benefits.

If you get your Medicare benefits through traditional Medicare (not a Medicare Advantage plan) and want more information, visit Medicare and Your Mental Health Benefits (PDF | 879.44 KB). To see if a particular test, item or service is covered, please visit the Medicare Coverage Database.

Q. What can I do if I think I need mental health or substance use disorder services for myself or family members?

Here are three steps you can take right now:

1. Learn more about how you, your friends, and your family can obtain health insurance coverage provided by Medicaid or CHIP or the Health Insurance Marketplaces by visiting HealthCare.gov.
2. Find out more about how the law is expanding coverage of mental health and substance use disorder benefits and federal parity protections: http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm
3. Find help in your area with the Behavioral Health Treatment Services Locator or the Find a Health Center.

Q: What is the Health Insurance Marketplace?

The Health Insurance Marketplace is designed to make buying health coverage easier and more affordable. The Marketplace allows individuals to compare health plans, get answers to questions, find out if they are eligible for tax credits to help pay for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs. The Marketplace Can Help You:

• Look for and compare private health plans.
• Get answers to questions about your health coverage options.
• Get reduced costs, if you’re eligible.
• Enroll in a health plan that meets your needs.

Learn more at HealthCare.gov.