How Essential Health Benefits Affect Treatments for Mental Health and Substance Use Disorders

Updated on March 8th, 2021

Reviewed by Diane Omdahl

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Maintaining your mental health is just as essential to well-being and happiness as your physical health. With 1 in 5 adults living with a mental illness in the United States, this category of public health greatly impacts our society. Moreover, mental and behavioral health treatments face unique social barriers, from public stigma to lack of comprehensive resources.

In 2014, the Affordable Care Act established 10 essential health benefits that every traditional health insurance plan must cover. Identified as an essential health benefit, mental health and substance use disorder services received federal recognition, igniting a nationwide conversation about mental health. Over the past few years, accessing affordable treatment for mental illnesses has become easier for individuals seeking help.

Once you have been clinically diagnosed with a mental illness or substance use disorder, you can consider treatment options to manage your symptoms. Whichever course of action you and your doctor decide to pursue, you’ll want to know if your insurance provider will cover it. Fortunately, most common services with professionals are covered by your health plan.

What’s in the Mental Health and Substance Use Disorder Services Benefit?

Mental or Behavioral Health Treatments: If you’re diagnosed with a mental disorder by a doctor, your therapy and other outpatient treatment options will likely be considered “medically necessary”. This means your health plan must cover sessions with a professional.

PsychiatristsPsychiatrists are medical doctors who are licensed to not only provide therapy with individuals but also prescribe medications, if necessary. They are trained to diagnose and treat mental illnesses as well as substance use disorders.
Psychologists Psychologists can help people with mental disorders through different forms of verbal therapy. They receive extensive training and must complete a doctoral degree in order to practice.
Mental Health    Counselors Mental health counselors are required to receive a master’s degree to help you manage your mental health condition. They’re problem-solvers who can guide individuals through treatment.
Licensed Clinical Social WorkersLicensed social workers hold a master’s or doctoral degree in social work to offer diagnoses and treatments for mental illnesses.
  • Other Therapies: Other treatments beyond conventional therapies for mental illnesses, may be encouraged by your psychologist or psychiatrist. For example, art, music, and drama therapies are all creative ways that allow individuals to express their feelings. Coverage for costs of services and supplies are evaluated per case by health insurance companies.

In your search for a mental health professional, it’s important to find out whether or not they accept health insurance plans. Certain psychiatrists and psychologists may only conduct their practice with complete control over their payments, and will not accept payment through insurance companies. Check with your health insurance company for a list of in-network mental health workers to reduce costs per session.

Inpatient Services: If you are pre-approved by a physician to stay at a rehabilitation facility, your visit should be covered by your health insurance provider. However, the number of consecutive days of stay that is included may differ from state to state.

  • Inpatient Rehabilitation for Mental Illnesses: Psychiatric hospitalizations and inpatient treatment programs at full-service mental facilities are a part of your health plan.
  • Inpatient Rehabilitation for Substance Use Disorders: Day-treatments, inpatient detox, and residential rehabilitation for people with substance use disorders can be covered by major health insurance providers.

Substance Use Disorder Treatments: Services to help individuals living with these disorders are included in your health plan. The following treatments will likely be covered depending on your health insurance provider and state you live in: medical detox, medication for addiction maintenance, follow-up counseling, and transitional recovery services.

What’s Not in the Mental Health and Substance Use Disorder Services Benefit?

Education and Training: Your health insurance may not cover extensive education and training beyond the scope of therapy and counseling sessions. For example, many health plans do not include mental health-related vocational therapy or resources for family members. However, with online resources at your fingertips, you can learn more about mental illnesses and substance abuse.

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Custodial Care: Daily assistance from non-licensed medical personnel is not considered an essential health benefit. Reimbursement for medical care from family members or friends will also not be covered.

Private Accommodations: If you require daily long-term care, a private room, or any other personal necessities as a part of treatment, your health insurance is not required to cover these costs.

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How Does This Relate to Other Essential Health Benefits?

  • Psychiatric Drugs: Prescription drugs, including medications to treat mental illnesses, are a separate essential health benefit under the ACA. Many people rely on their health insurance company to cover the cost of pharmacological treatments.
  • Some Preventive Screenings: Under other essential health benefits, such as preventive care, screenings for some mental health illnesses should be covered. Examples include screenings for depression, alcohol misuse, and tobacco use. Screenings are crucial in detecting illnesses at an early stage to avoid the development of more severe symptoms.

If you are seeking substance use or mental health treatment, it’s important to determine what services your health insurance provider will cover. Your provider should give you a better idea of the therapies and services that are specific to certain illnesses.

What Does “Covered” Mean?

After you see a mental health professional, you can expect to pay for the visit if he or she accepts health insurance. When your insurance provider covers medical services, including mental health treatments, you also have to contribute to the costs. This can either be in the form of a copayment or coinsurance.

Covered Just Like Any Other Service: You don’t have to worry that the costs for mental health treatments will be more than what you pay for physical health services. The Mental Health Parity and Addiction Equity Act, passed in 2008, helped close the gap for physical and mental health treatments. This law requires coverage for mental health and substance use disorder services to be comparable to physical health services.

Therefore, insurance companies have to charge nearly equal amounts whether you visit a psychologist or a medical doctor. Finances and treatment cannot be restricted for mental health services when compared to other services.

With HMO-type plans, your doctor may need to write a referral before you can see a mental health worker. With other plans, you can visit the provider directly, without prior authorization.

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Looking for Health Insurance?

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If you continue sessions with a therapist over an extended period of time, your health insurance can periodically reevaluate whether they are “necessary”.

Remember, your mental and emotional health are equally as important as your physical health. By including mental health and substance use disorder services as an essential health benefit, individuals can take the next steps in affording treatment.

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