Mental Health and Insurance

Having health insurance coverage can help provide some sense of security for consumers who may be worried about seeking the adequate services for their healthcare needs. Mental health services in particular have historically been an area lacking in adequate and fair health coverage, hence the implementation of the Mental Health Parity Law (MHPAEA), so it is crucial to learn about what you have as options for care. Click to expand each section to better understand how to navigate getting the mental health care you need depending on your insurance situation.

If you have health coverage through an employer-insured health plan: 

Individuals who have coverage through an employer should check the Summary of Benefits and Coverage (SBC), a description of your company’s health benefits package. This should include information on what kinds of services are covered, including mental health and behavioral services. Employers often pay some or all of the monthly premiums, but it is important to understand what expenses you will be responsible for across all your healthcare needs. As a reminder, the Mental Health Parity Law does not require that all employer-sponsored health plans must include mental health coverage; rather, the law ensures that if your plan does include mental health services, that its costs not be more stringent than other medical costs. For employers that offer several options for healthcare plans, it is important to review each one and understand the mental health services offered, if they are included. If you were already seeing a healthcare provider for mental health services prior to your employer-sponsored coverage, it is equally important to check if those providers, as well as the medications you may be taking, are then included in the network of providers and covered treatments under the available health plans. Often, the types of mental health services that are typically covered by employer-based health plans are emergency care, outpatient mental health treatment, inpatient hospitalization, partial hospitalization, and prescription drugs.

Another section to look out for in your health plan is the criteria for “medically necessary treatment,” which will vary between plans, and the criteria for what your insurer deems as medically necessary will also vary. You can always request these documents for the kind of treatment you are interested in, mental health-related or otherwise. This is especially important since you may be able to apply for an exception or appeal a typically non-covered service or treatment, if you find that it meets your insurers “medically necessary” criteria. Reviewing this criteria will help you determine what kind of treatment options you have and the costs related to them, and help avoid unforeseen medical bills. TCHS recently penned a helpful article on managing medical debt, which can be found here.

It is also a good idea to look into any workplace wellness programs or services your employer may offer, in addition to your employer-based health coverage. Our 2018 Consumer Survey found that of the 58 percent of respondents who reported that their employer offered managed programs for substance abuse or mental health, only 22 percent were enrolled in these programs. To get the most out of your employee resources and better understand your benefits, you can also contact your benefits office or human resources department at your employer. If you still have questions about whether your plan covers mental health services (or if you have been denied coverage, reached a limit on your plan, or an overly large copay or deductible), you can visit the Mental Health and Addiction Insurance Help Portal from the HHS website.

If you have insurance through a State Exchange:

The Affordable Care Act (ACA), which remains law in the United States as of 2018, requires that state and federal health insurance Exchange plans have coverage at minimum of ten Essential Health Benefits, one of which is mental health and substance use disorder services, and includes behavioral treatment (such as counseling and psychotherapy). Some state health insurance Exchanges have additional medical management programs. Our TCHS State Exchange Guide can help you better understand the plans and additional management programs available in your state. With the ACA requirement of covering pre-existing conditions, plans through a state health insurance Exchange cannot deny you coverage of your pre-existing mental health and/or substance use disorder conditions. These plans also cannot have lifetime or annual dollar limits on coverage for Essential Health Benefits. Since these marketplace plans are subject to the Mental Health Parity Law, the limits placed on finances, treatment, and care management for mental health and substance use disorder services cannot be more restrictive than those applied to medical/surgical services. Depending on your income, you may be eligible for certain financial assistance to pay for your health coverage. When you apply for coverage through an Exchange, your eligibility will be determined for Medicaid, cost sharing reductions, or a premium tax credit.

  • Cost Sharing Reductions: If your income qualifies for this reduction, you may be able to pay less out-of-pocket when you receive medical services. However, you can only receive these savings if you enroll in a plan in the Silver category. You will likely have more savings if your income is lower and within the range to qualify. You can read more information on how cost sharing reductions could affect your out-of-pocket costs here.
  • Premium Tax Credit: This tax credit may lower your monthly premium, or the amount you pay to your insurance plan each month, and depends on the estimated household income that you report for the year you apply for Marketplace health coverage. Some or all of this credit can be applied to your monthly insurance premium payment, and the Marketplace can send this to your insurance company as “an advance payment of the premium tax credit.” Increasing your household income or losing a member of your household will likely qualify you for a lower premium tax credit, and a decrease in your household income or gaining a household member may qualify you for bigger premium tax credit. Premium tax credits can be used in any plan in any metal category, unlike the savings from cost sharing reductions.
  • Medicaid: See below under 'If you are Uninsured'

For service members and veterans:

Veterans eligible for healthcare from the Department of Veteran Affairs (VA) have access to several forms of mental healthcare services. The Department of Veterans Affairs Medical Facilities are operated by the federal government and serve only veterans and, in some cases, eligible beneficiaries such as spouses and/or children. At times these beneficiaries may be eligible for CHAMPVA, a type of federally provided insurance issued through the VA. Similar to CHAMPVA, yet issued by the Department of Defense to eligible active service members, their beneficiaries and some retirees, is another form of government sponsored insurance, TRICARE. While the three primary mental health concerns for veterans and service members are post-traumatic stress disorder, depression, and traumatic brain injuries, a study from 2014 reported that nearly one in four service members returning from deployment in combat zones had shown signs of a mental health condition. However, the Substance Abuse and Mental Health Services Administration reports that only 50 percent of returning service members seek treatment for mental health conditions. This is concerning as suicide rates among veterans and service members who do not use VA services have increased by 38.6 percent since 2001, according to a report conducted in 2016 by the VA. For women veterans specifically, suicide rates have increased by 85 percent since 2001, and women veterans are 250 percent more likely than women civilians to commit suicide. With this in mind, inadequate access to and treatment for mental health of veterans can be debilitating for veterans in our community. Seeking the help of a primary care doctor or the resources provided by the VA can often be a good start for veterans and service members to find the right mental health services they need. TCHS has a general guide to Veteran healthcare options, as well as how to access TRICARE, which can be viewed here. 



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The VA also offers Service-Connected Disability Compensation, which provides a tax-free benefit paid monthly to Veterans who are “at least 10 percent disabled because of injuries or diseases that were incurred in or aggravated during active duty, active duty for training, or inactive duty training.” Physical as well as mental health conditions are included, and you will need both medical evidence of a current disability as well as evidence of relationship between your disability and an event, injury, or disease in military services. To read more about how to apply, whether you are eligible, and how the benefit compensation works you can visit the VA benefits website here. The VA website additionally has several other resources directing veterans to specific mental health needs, as well as other training programs to help veterans and service members transitioning back into civilian life.

Though not originally under the requirements of the MHPAEA, as of October 2016, TRICARE expanded its services to include access to mental health and substance use disorder treatment to ensure that co-pays were not more expensive than other medical/surgical treatment. The new rule also removes annual limits for inpatient and residential mental health treatment stays, and adds opioid addiction outpatient treatment. There are several types of TRICARE plans, and the full list of covered mental health services can be found on the TRICARE website. VA facilities are also under the TRICARE network of providers, providing both inpatient and outpatient mental health and behavioral health services.

If you have Medicare:

Medicare is the national health program for people age 65 and over, though it does also cover some non-elderly people, such as those who receive Social Security Disability Insurance (SSDI) payments, those diagnosed with end-stage renal disease, or those diagnosed with amyotrophic lateral sclerosis, ALS or commonly known as Lou Gehrig's Disease. This government-funded program is critical for many older adults, especially since the National Council on Aging reports that one in four older adults ages 65 and older experiences a mental health problem, such as dementia, and depression and anxiety disorders, and this number is predicted to double to 15 million by 2030. Combating the stigma against both aging and mental illness by spreading awareness of the resources available for access is a necessary route toward caring for older adults who may be at risk of inadequate mental healthcare. Being healthy at any age involves the understanding that both your mental and physical health correlate, and older adults who have higher rates of physical diseases may have higher rates of mental health diagnoses.

Medicare has several components and as of 2014, the Mental Health Parity Law was extended to only Medicare Part B (Medical Insurance) outpatient expenses for mental health care. Our Medicare Guide has further information on applying for Medicare and general services covered.

Medicare Part B - Mental Health Professionals and Covered Care

Medicare Part B covers mental health counseling or therapy visits only if they are from a provider who agrees to accept payments from Medicare directly. Mental health services and visits from the following types of mental health professionals are covered under Part B (should they accept Medicare payment):

  • Clinical Psychologist
  • Psychiatrist or other Doctor
  • Clinical Nurse Specialist
  • Nurse Practitioner
  • Physician Assistant

Other services in settings outside of a hospital, such as a doctor or healthcare provider’s office, a community mental health center, or a hospital outpatient department, are also covered, as well as treatment for substance use disorder. 

 The covered outpatient services that Part B can help pay for include:

  • Individual and group psychotherapy with doctors/licensed professions that are allowed by the state you are receiving services
  • Family counseling (if the main purpose is assisting with your treatment)
  • A yearly depression screening, which must be done at a primary care doctor’s office or primary care clinic that can provide follow-up treatment/referrals
  • A yearly “wellness” visit, where you can discuss changes in your mental health with your doctor or other healthcare provider and evaluate changes from year to year
  • Psychiatric evaluations and diagnostic tests
  • Testing to determine if you are receiving the services you need and whether the current treatment is helping you
  • Medication management
  • Certain prescription drugs, such as some injections, that are not usually “self-administered”
  • Partial hospitalization

There is no charge for your yearly depression screening if the doctor or healthcare provider you see accepts Medicare payments directly. You will be responsible for 20 percent of the Medicare-approved amount for doctor or healthcare provider visits, the Part B deductible (which can vary each year), and possible additional co-payments or coinsurance amounts to a hospital department for certain outpatient services. Be sure to ask your doctor or healthcare provider any questions you may have to clarify how much the tests, services, and other treatments you need will cost.

Prescriptions Through Medicare

If you have Medicare Part D Prescription Drug Plan coverage, the costs and the drugs covered will vary since these are run by insurance companies and other Medicare-approved private companies. You can look up your plan’s formulary, which is a list of the drugs your plan covers. Almost all drugs classified as antidepressants, antipsychotics, and anticonvulsants are required to be covered by these plans, though some exceptions do exist. If your plan makes any changes to its formulary during the year, it must either:

  • Provide at least a 60-day notice prior to the date the change is effective
  • Or provide a written notice of the change and 60-day supply of the drug under the same plan rules as before the change, when you ask for a refill

If you are unsure if your drug plan will cover a certain drug, you have a right ask your Medicare drug plan for coverage determination, upon which they are required to give you a decision in 24 hours for expedited requests, or 72 hours for standard requests. If you disagree with the coverage determination, you can attempt to appeal for coverage. To find more information appeals, visit Medicare.gov/appeals.

Covering Mental Health Prescriptions

Mental health prescriptions can often be costly for some, but there are some resources available to assist with these payments. The following are some options to consider:

  • Should you meet the income and resource limits, you may be eligible for help paying for your Medicare prescription drug costs. You can apply for Extra Help online at the Social Security website at socialsecurity.gov/i1020. All are encouraged to apply even if you are not sure if you qualify.
  • Medicare Savings Programs through which you can receive help from your state to pay for Medicare costs (such as deductibles, coinsurance, and premiums) are also an option if you have limited income and resources. You can visit your state’s Medical Assistance (Medicaid) Office and ask about the Medicare Savings Programs in your state. You can find the phone number for your state’s office by visiting Medicare.gov/contacts, and choosing ‘State Medical Assistance Office’ in the drop down menu.
  • State Pharmacy Assistance Programs (SPAPs) are available in many states and can help some people pay for prescription drugs. Use the State Pharmaceutical Assistance Program locator from the Medicare.gov website to see if your state has SPAP and for information on how to apply.

The Centers for Medicare and Medicaid Services (CMS) have a helpful guide, Medicare and Your Mental Health Benefits, which gives consumers further detailed information on understanding their healthcare options.

To find the right Medicare plan that works with your mental health needs, and to help better understand the options available to you, visit the Medicare QuickCheck® website, sponsored by Mental Health America and the National Council on Aging.

If you are Uninsured:

A national report from the mental health organization Mental Health America(MHA) in 2017 reported that about 17 percent of adults with a MI are uninsured, which translates to over 7.5 million people. Paying for mental health services without insurance can be costly, but there are some options available to you and your loved ones until you are able to get stable health coverage.



Medicaid:
Medicaid is a joint state and government run program for disabled persons, low income adults, and pregnant women. Research has shown that lower income communities can have higher rates of mental health issues, so Medicaid programs can be an option for individuals if they need coverage for their treatment. Medicaid has been the largest payer of mental health related services in the United States, and since the passage of the ACA, 1.2 million individuals with substance use disorders have been able to access coverage in the 31 states that expanded Medicaid. The CMS released new rules in March 2016 which expanded mental health parity law to apply to Medicaid Managed Care Organizations (MCOs) and Medicaid Alternative Benefit Plans (ABPs), so Medicaid providers cannot impose unfair and more stringent financial requirements, treatment limitations and information availability requirements (“medically necessary” criteria) on mental health and substance use disorder services. In fact, some states have even stricter parity laws that ensure specific aspects of mental illness and treatment are covered. For example, California law requires that government-funded healthcare plans include coverage for treatment of serious mental illnesses, such as schizophrenia, while other states may only cover certain mental illness care. It should be noted, however, that parity does not apply to what is referred to as “traditional Medicaid,” or fee-for-service Medicaid, so it is important to verify with your provider the kind of care you are receiving.

Every state deploys their Medicaid guidelines differently. You can view our State-by-State Medicaid Guide on the TCHS website and learn how to apply for Medicaid in your state.

Community Health Centers:
Community health centers, funded by the Health Resources and Services Administration (HRSA) from the HHS, can be a good starting point for individuals who cannot afford health insurance. These community-based and patient-directed facilities serve as a low-cost option for individuals to receive comprehensive primary health care as well as other supportive services with adjusted fees based on an individual’s ability to pay. The HHS reports that there are over 1,300 community health centers around the nation, and over 26 million Americans depended on an HRSA-funded centers in 2016 to access affordable primary healthcare. In particular, 10 percent of patient visits to these clinics were for mental health and substance use disorder services, according to a Kaiser Family Foundation report. This same report also found that mental health services offered grew from 73 percent to 87 percent between 2010 and 2016, indicating that consumers have a higher chance of finding a local health center that offers the critical mental health services they may be seeking. While not all community health centers include behavioral health and substance use services, many do include such care (termed “additional health services”), so be sure to check if your local clinic has the kind of treatment you are looking for.

You can use the HRSA Center Locator to find a health center near you.

Children’s Health Insurance Program (CHIP):
The Children’s Health Insurance Program (CHIP) is a joint state and government funded program that provides health coverage through Medicaid and other CHIP programs to children up to age 18 and families that may earn too much money to qualify for Medicaid, but not enough to cover private insurance costs. The Centers for Disease Control and Prevention estimate that up to one in five children experience a mental disorder in a given year. An estimated 9.4 million children were covered by CHIP in 2017, and since the expansion of the mental health parity law’s application to CHIP (including fee-for-service and managed care) in March 2016, more children have been able to access the behavioral health services they need CHIP guidelines, much like Medicaid guidelines, are deployed by each state a little differently, so eligibility for coverage may vary. Application for coverage is year-round, and can begin immediately if you qualify. You can apply for CHIP two ways:

  • Over the phone at 1-800-318-3596
  • Or applying through the Health Insurance Marketplace, which notifies you if your household qualifies for either Medicaid or CHIP. If you do qualify, information about your state agency can be sent to you, along with information about whether you qualify for any other insurance savings options.

CHIP generally covers the same things as Medicaid, but specific benefits can be different from state to state. Basic coverage includes:

  • Immunization
  • Prescriptions
  • Dental and vision care
  • Inpatient and outpatient hospital care
  • Laboratory and X-ray services
  • Emergency services
  • Routine check-ups

Again, since each state runs their Medicaid and CHIP programs differently, it is important to verify what your state’s program offers as they may have additional services that could benefit your child’s needs. The Mental Health and Addiction Insurance page on the Department of Health and Human Services (HHS) website can be a helpful way to start looking at what your state offers. Select the ‘Medicaid or Children’s Health Insurance program (CHIP)’ option and the state you reside to get more information on how to access health insurance for your child. Your child’s primary care doctor can also be a helpful starting point to begin a discussion on your child’s mental health, and point you in the right direction of treatment options.

Other Community Behavioral Health Facility Options, Low-Cost, and Free Services:
Often times there are already facilities and centers that specifically cater to community members’ mental health and/or substance use disorder needs, providing services at a lower cost or working with patients’ individual financial abilities. These can range from grassroots and nonprofit advocacy organizations, private organizations, The following are some examples to look out for in your community:

  • Mental Health America Affiliate Locations are nonprofit organizations that can be found in 41 states and helps patients navigate the often difficult mental health system, providing education, support services, rehabilitation services, and many other helpful resources. They also have advocacy services to parents with children diagnosed with a serious mental illness, mentorship and peer support for recover adults, and other professional education for professionals working in the mental health field.
  • Substance Abuse and Mental Health Services Administration also features local behavioral health treatment facilities locator where you can specify the kind of services you are looking for (e.g. substance use, mental health, general health centers, etc.) as well as your insurance type (e.g. Medicaid, Medicare, etc.) and payment ability (e.g. sliding scale fee, cash, etc.).
  • Certified-Community Behavioral Health Centers (CCBHs) receive Medicaid reimbursement for their mental heath and substance use disorder services based on their costs of providing for vulnerable individuals. There are nine types of services that CCBHs must provide, featuring 24-hour crisis care, care coordination, evidence-based practices, and integrated physical care. These facilities are currently only available in 8 states (Minnesota, Missouri, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania), but with the potential to expand to others. Contact information for these centers can be found here.
  • The National Association of Free & Charitable Clinics can help you locate a clinic near you that can provide low-cost care. Keep in mind that not all of these clinics are the same or have the same services available, so it is important to verify with the clinic whether their services match your mental health needs.
  • With over 1,000 National Alliance on Mental Illness (NAMI) Affiliate Locations and state organizations, NAMI can be a helpful resource for many to receive free support and educational programs.
  • For those in organized religious groups, spiritual community leaders can be another option for low cost, often free, support groups, retreats, and counseling.
  • Common across the country are university training clinics, meant for students of health and medicine to practice working with the public. Clinical or counseling psychology students, supervised by a licensed psychologist, can conduct low-cost sessions for patients, and these clinics often charge on a sliding scale fee. You can find a list of training clinics from the Association of Psychology Training Clinics.

Navigating Mental Health:


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