Does ACA insurance cover mental health services?
Are mental health and substance abuse treatments covered under my ACA health plan?
Yes, all ACA-compliant health insurance plans are required to cover mental health and substance abuse treatments as part of the essential health benefits package. This includes a wide range of services for mental health disorders and substance use disorders. Importantly, the ACA mandates parity, meaning that mental health and substance abuse services must be covered at the same level as physical health services, with similar cost-sharing structures (such as copayments and coinsurance). Here’s what you need to know about how your ACA plan covers these critical services:
1. What Mental Health and Substance Abuse Services Are Covered?
All ACA plans must cover both mental health services and substance use disorder treatments. These services include:
A. Mental Health Services
Therapy: Individual or group therapy sessions with licensed mental health professionals such as psychologists or counselors.
Psychiatric care: Services from psychiatrists, including mental health evaluations and medication management for mental health conditions like depression, anxiety, and bipolar disorder.
Inpatient mental health services: If you require hospitalization for mental health treatment, inpatient services are covered, including stays in psychiatric hospitals or inpatient mental health facilities.
Outpatient mental health services: Services such as counseling, psychotherapy, or consultations that do not require hospitalization.
Preventive services: Screenings for mental health conditions such as depression.
B. Substance Abuse and Addiction Treatment
Detox programs: Medically supervised detoxification to help patients safely withdraw from addictive substances.
Inpatient treatment for substance use disorders: This includes residential treatment programs where patients receive 24-hour care for addiction recovery.
Outpatient treatment programs: Outpatient rehabilitation programs allow patients to receive treatment while continuing to live at home. This includes counseling, therapy, and support groups.
Medications: Certain medications used in medication-assisted treatment (MAT) for addiction, such as for opioid use disorder, are covered.
Counseling and behavioral therapies: These treatments include individual and group counseling sessions aimed at managing addiction and preventing relapse.
2. What Is Parity in Mental Health and Substance Abuse Coverage?
Under the ACA, parity means that your insurance plan must treat mental health and substance use disorder services equally to physical health services in terms of:
Cost-sharing: Your copayments, coinsurance, and deductibles for mental health or substance abuse treatments must be comparable to those for medical or surgical services.
Treatment limits: There cannot be unreasonable limits on the number of therapy visits or counseling sessions covered, as long as those limits do not apply to physical health treatments.
Pre-authorization requirements: The rules for getting pre-authorization for mental health or substance abuse services must be the same as for other types of medical services.
3. How Much Will I Pay for Mental Health and Substance Abuse Services?
The amount you pay for mental health and substance abuse services will depend on your plan’s cost-sharing structure, including:
A. Deductibles: You may need to meet your plan’s deductible before the insurance starts covering mental health and substance abuse services. However, some services like therapy sessions may have a copay even before your deductible is met.
B. Copayments and Coinsurance:
Copayments: A fixed amount you pay for each visit to a therapist, psychiatrist, or treatment facility. For example, you might pay $25 per session for therapy, depending on your plan.
Coinsurance: A percentage of the cost of the service that you pay. For instance, you might be responsible for 20% of the cost of an inpatient treatment stay after meeting your deductible.
C. Out-of-Pocket Maximum: Your out-of-pocket costs for mental health and substance abuse services count toward your plan’s out-of-pocket maximum. Once you reach this limit, your plan will cover 100% of all covered services for the remainder of the year.
4. Are There Any Limitations on Mental Health or Substance Abuse Coverage?
While ACA plans are required to cover mental health and substance abuse services, certain limitations may apply. It’s important to check your plan for:
Pre-authorization requirements: Some services, such as inpatient mental health treatment or residential rehab, may require pre-authorization from your insurance company.
Network restrictions: For lower costs, make sure to use in-network providers for mental health and substance abuse services. Going out-of-network may result in higher costs or no coverage.
Medication coverage: If you’re prescribed medication for mental health or substance use disorder, check your plan’s drug formulary to see if your medication is covered and at what cost.
5. How to Access Mental Health and Substance Abuse Services
Contact your insurance provider: Reach out to your health insurance company to find in-network therapists, counselors, or treatment facilities and confirm your coverage details.
Find in-network providers: Using in-network mental health professionals and substance abuse treatment facilities will help you maximize your coverage and keep costs down.
Explore online resources: Many ACA plans offer access to telehealth services for mental health counseling and therapy, which can be more convenient and affordable.
Key Takeaways:
All ACA-compliant health plans must cover a broad range of mental health and substance use disorder treatments, including therapy, inpatient care, and medications.
Under ACA parity rules, mental health and substance abuse services must be covered at the same level as physical health services, with similar cost-sharing.
Coverage includes both inpatient and outpatient treatments, along with counseling, rehabilitation, and medication-assisted treatment.
For personalized assistance in accessing mental health or substance abuse services and understanding your coverage options, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
