The Mental Health Parity and Addiction Equity Act and the Affordable Care Act have made mental health and substance use disorder treatment accessible to millions. Not only have these Acts mandated insurance coverage for these disorders, but they require it to be comparable to levels provided for treatment of other health conditions.
Why should you use your insurance to cover mental health and substance use disorder treatment? Mental health disorders, including substance use disorders, are covered by essential health benefits. You have a right to expect your health insurance to cover necessary treatment. These Acts ensure your rights of coverage and parity.
Parity means to be equal or comparable. The Mental Health Parity and Addiction Equity Act (MHPAEA) requires qualified health insurance plans to provide levels of coverage for mental health and substance use disorder treatment to be equal to what they provide for other physical disorders and diseases.
The National Conference of State Legislatures (NCSL) further explains that the benefits provided must be equally “applied to visit limits, deductibles, copayments, and lifetime and annual limits.” The NCSL notes that various state and federal actions may impact mandates of the MHPAEA.
For information on how the MHPAEA protects your benefits, see the Substance Abuse and Mental Health Services Administration (SAMHSA) fact sheet entitled “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits.”
Affordable Care Act expands mental health and substance use disorder coverage
The Patient Protection and Affordable Care Act, commonly referred to as the Affordable Care Act (ACA), was signed into law on March 23, 2010. The most significant provisions became effective in January 2014, although some changes did take effect before then.
Under the Affordable Care Act, the U.S. Department of Health and Human Services estimated, “32.1 million Americans will gain access to coverage that includes mental health and/or substance use disorder benefits that comply with federal parity requirements and an additional 30.4 million Americans who currently have some mental health and substance abuse benefits will benefit from the federal parity protections.”
The ACA expanded MHPAEA parity requirements to apply to more health plans. Previously, small employer-funded plans (less than 50 employees) and certain other plans were exempt from MHPAEA requirements. Small business health plans are no longer exempt.
The ACA also requires that mental health care be classified as an “essential health benefit” under the law. Before the enactment of the ACA, health insurance plans that didn’t cover mental health or substance use disorder were exempt from parity requirements. Now, insurance plans must cover mental health and substance use treatment as essential health benefits, at parity with other physical disorders and diseases.
As an essential benefit, covered mental health and substance use disorder services include evaluation and diagnosis, behavioral health treatment, counseling, and psychotherapy. Policy holders should review their plan carefully, as there may be certain limits and specifications. Non-exempt plans that don’t provide mental health and substance use disorder coverage are in violation of federal and state law.
The ACA prohibits health insurers from denying insurance coverage or treatment coverage on the basis of a “pre-existing condition,” including pre-existing mental health or substance use disorders. This means those without insurance who need treatment can apply for a health plan without fear of denial on the basis of a pre-existing condition.
Coverage of mental health and substance use disorder treatment
Mental health disorders and substance use disorders are complex diseases. As such, effective treatment requires a team of addiction specialists, often including physicians, nurses, medical health counselors, clinical therapists, addiction counselors, nutritionists, and other recovery support staff. Treatment can be costly, but a health plan that provides some degree of coverage can help make it more accessible.
Those with a substance use disorder may not realize their health insurance will cover, or partially cover, treatment services that are “medically necessary.” Medical necessity is defined by Healthcare.gov as “health care services or supplies needed to diagnose and treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of care.”
Once a physician has determined mental health or substance use treatment to be medically necessary, most insurance policies will provide full or partial coverage of:
- Assessment by an addiction treatment facility
- Medical detoxification (detox)
- Addiction treatment and maintenance medications
- Inpatient care in an approved facility
- Outpatient care with an approved provider
- Co-occurring mental health disorders
- Counseling, including family counseling
Insurance plan coverage can be difficult to decipher. Pursuant to the Affordable Care Act, the U.S. Department of Health and Human Services now requires insurance providers to furnish a one-page summary of benefits and associated fees. For answers to insurance questions about mental health and addiction treatment services see the mentalhealth.gov website.
How can you find an appropriate treatment program?
When considering a treatment program for mental health or substance use disorders, or both, it’s important to do your research. Personal physicians are a good place to start, as they know your medical history and can offer referral resources.
Before committing to a treatment program, either visit or call the facility and speak to a staff member well versed in all aspects of the programs. Gather the following information:
- What licenses and credentials does the facility and staff have?
- What are the specifics of the program you’re considering? Will it be inpatient, outpatient, or both?
- What does a typical day look like? What is the program’s success rate? Is treatment evidence-based? How long will the program last?
- If appropriate, how is detox handled?
- What follow-up care is provided?
- Exactly what will your insurance cover and what out-of-pocket expenses should you expect?
Finding a program that is the best fit for you, especially a program with a proven track record, is also a vital key to a successful recovery.
If you’re having trouble finding a treatment program that meets your needs, the Substance Abuse and Mental Health Services Administration (SAMHSA) website has information on thousands of state-licensed providers who specialize in treating substance use disorders and mental health disorders.
Turning Point of Tampa’s goal is to always provide a safe environment and a solid foundation in 12-Step recovery, in tandem with quality individual therapy and groups. We have been offering Licensed Residential Treatment for Addiction, Eating Disorders and Dual Diagnosis in Tampa since 1987.
