Our mental well-being is just as important as physical health. Yet sometimes the cost can prevent us from speaking with a mental health professional. Health insurance companies may provide sufficient coverage for physical illness, but what about mental illness? Does insurance cover therapy?
With one out of every five U.S. adults experiencing mental health issues, you’re not alone in asking before you book an appointment.
Does Insurance Cover Therapy?
Most health insurance plans cover at least some forms of mental healthcare. The Affordable Care Act (ACA) requires most plans sold on the Marketplace to cover mental health and substance use disorder services. Employer-sponsored plans often include coverage of mental health treatment, and so do plans purchased through health insurance exchanges created under the Children’s Health Insurance Program (CHIP), and most Medicaid programs.
Don’t let cost be the barrier preventing you from getting care. We all need a little extra help to nurture our well-being. The right coverage pays for mental health services, inpatient treatment, therapy sessions, and prescription drugs.
Does Your Plan Cover Mental Health? How To Find Out
You may be able to determine if your plan covers mental healthcare by looking at its documentation. If it’s unclear, the best way to get the answer is to ask. The answer may be nuanced, and the documentation may not cover every situation.
If you have an employer-sponsored plan, talk with a member of the human resources staff. He or she may provide additional clarity. When you call to book an appointment, ask your healthcare provider whether mental health services are covered under your plan.
Also, ask whether your insurance company will be billed directly. In that case, you will only pay a copayment. If your provider does not bill the insurance company directly, you will need to pay in full and submit a claim to your insurance company for reimbursement.
How much does insurance cover therapy? It depends on your plan’s fees, such as copays and deductibles. Be sure to check your plan’s documentation for specific fees, or ask when booking an appointment.
Mental Health Services Under The ACA
ACA Marketplace policies must cover “mental health and substance use disorder services” as one of ten “essential health benefits.” All health insurance plans sold through the marketplace have to cover these essential health benefits.
The ACA makes it illegal for health insurance companies to deny you coverage or charge you more because of previously existing mental health issues. It also makes it illegal for health insurance companies to place yearly or lifetime dollar limits on mental health coverage. Plans must cover behavioral health treatment, counseling, psychotherapy, inpatient services, and substance abuse treatment.
The benefits of these policies may still vary. How much does insurance cover therapy? Plans differ, so when shopping for an ACA health plan, contact the companies directly to ask what the plan covers and to what extent. Ask about the mental health coverage specific to your needs.
Therapy And Counseling Under Medicaid Coverage
State Medicaid programs cover mental health services and substance abuse services, and Medicaid usually pays part of the cost for counseling or therapy, but not always. Contact your local agency to make sure your needs receive coverage. These services may include therapy, medication management, social work services, peer support, and substance use disorder treatment.
If you are seeking counseling or therapy for a child who needs care, CHIP may be a better option, especially if you have financial need. CHIP is a Medicaid-related program that provides a wider range of mental health services to children.
Psychiatrist Visits, Therapists, And Counseling Under Medicare Coverage
Does insurance cover therapy under Medicare? Yes, Medicare coverage can help pay for mental healthcare services. According to medicare.gov, the three types of coverage include hospital insurance, medical insurance, and prescription drug insurance.
Medicare Part A (Hospital Insurance)
This helps pay for hospital stays, including the room, meals, therapy and treatment, lab tests, medication, and nursing care. Medicare does not cover a private room, unless necessary. It also does not cover a phone or television in your room, personal items like a toothbrush or a razor, or private duty nursing.
Medicare Part B (Medical Insurance)
This helps pay for mental healthcare provided in a clinic, from a therapist, at a community health center, or from a hospital’s outpatient services. However, if you become partially hospitalized, Medicare does not cover meals, transportation, support groups, or job-skill testing or training not tied to your mental health treatment.
Medicare Part D (Prescription Drug Insurance)
This covers many drugs that prevent mental illness, but not all. Nearly all anticonvulsant, antidepressant, and antipsychotic medications will be covered by Medicare, but it’s important to check whether your necessary prescriptions are covered before enrolling. If you have a Medicare prescription drug plan, you can ask your plan to provide or pay for a drug prescribed to you. You can appeal your plan’s decision about including the drug in coverage.
But first, talk with the healthcare provider who wrote the prescription. Your plan may have special coverage rules. A healthcare provider or doctor may also recommend generic or over-the-counter drugs that will work as effectively as the ones you have been prescribed.
For more on how to request a coverage determination, exception, or appeal, go to cms.gov.
How Much Does Insurance Cover Therapy?
Every health plan is different. Examine your policy to figure out how much of your therapy is covered. Look for information related to copays, deductibles, co-insurance, and out-of-pocket limits.
You may also contact the insurance company that provides your coverage. Talk to your doctor or healthcare provider before you agree to any test or treatment. How much you pay depends on the price your physician or healthcare provider charges for treatment, and any other insurance you have.
A federal law passed in 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, requires that insurance companies treat mental health and substance use disorder coverage equal to coverage for physical illness, and equal treatment includes financial parity. The law applies to employer-sponsored plans, as well as coverage purchased through health insurance exchanges created under the ACA, CHIP, and Medicaid.
Check For Copay Costs
Your insurance company may require you to pay a copay. The copay is an out-of-pocket charge for a specific service. If required by your insurance company, you will need to pay the charge for each office visit and treatment.
Ask about the cost of a copay before booking with your service provider.
If mental health or substance use disorder services are offered, they are subject to the parity protections. Because of the federal parity law, insurance companies must treat mental health coverage equal to medical or surgical coverage. They must treat financial requirements equally as well, so copays for mental health professionals must not be higher than those for physical health visits.
Mental health visits had higher copays than most medical visits in the past, but that should no longer be the case.
Check Whether You Pay A Deductible
Another addition to your mental healthcare cost is the deductible you pay out of pocket before your health insurance begins to make payments on claims.
Check your coverage documentation for the deductible cost. The deductible cost tells you how much you will need to pay before the insurance company makes any payments. For example, if your deductible is $500, you will pay that cost out of pocket before your insurance begins to pay the claim.
The deductible you see on your insurance documents applies to both mental and physical health coverage.
Out Of Network?
Patients often pay more out of pocket at an out-of-network provider. Call your insurance provider to ask whether your coverage uses provider networks, and visit the company’s website for a list of in-network providers.
Parity Law Violation
Insurance companies must treat therapy and counseling like any other trip to the doctor. Who should you talk to if you think your insurance company is violating the parity law?
If your insurance was obtained through your employer, the Human Resources department can put you in touch with a healthcare advocate who can help you submit an appeal. HR may have a record of other employees with similar issues. They will often work with the insurance company to make sure all benefits meet employee needs.
Be sure to ask your Human Resources department for an explanation of your coverage’s benefits, or contact your insurance company directly, before making an appeal.
If your insurance is not provided by an employer, reach out to the insurance company directly. It may also be necessary to speak with the insurance company if your company does not have an HR department. Locate the customer service number, often available on the back of your insurance card.
You can reach out to your state insurance commissioner if you obtained insurance through an exchange.
Are All Diagnoses Covered By The Parity Law?
While the federal parity law applies to all mental health and substance use disorder diagnoses, a health plan may have specific exclusions for certain physical illnesses and mental health issues. Your plan’s documentation should clearly disclose the exclusion.
Are There Any Other Exceptions To The Federal Parity Law?
Parity does not mean that all fees need to be exactly the same. For example, an insurer can charge a lower copay when you see your primary care physician than for therapy; however, this is only the case when the copay is equally high for other medical or surgical copays.
The federal parity law does not require insurance companies to cover mental health disorders. It only applies to insurance providers that cover mental health in addition to physical health. It doesn’t apply to some state government employee plans. It also doesn’t apply to Medicare coverage. Not every carrier in the U.S. covers mental health.
Does insurance cover therapy? Your insurance provider has the answer; if your plan doesn’t cover therapy, consider contacting HR or switching providers. The parity law encourages increasing numbers of providers to include therapy coverage, because we all want to care for our minds and well-being at a cost that fits our budget.