Mental health and substance abuse disorders affect a substantial amount of individuals in the United States. It is estimated that 1 in 5 adults in the United States are living with a mental health condition and 1 in 10 adults are living with a substance use disorder. Mental health issues are so prevalent that it is estimated that 50% of all Americans will be diagnosed with a mental illness at some point in their life.
Did you know?
Most health insurance plans (including Medicaid, Medicare, employer-sponsored group health plans and individual health insurance coverage plans) must cover certain health benefits. These health benefits include physical health, mental health, and substance use disorder services paid for by health plans. These plans are required by law to offer equivalent benefits for mental health and substance use disorders as they offer for medical/surgical services.
What does that mean?
Financial requirements, such as copayments, deductibles, the number of visits that your insurance will pay for mental health and substance use services must be comparable to what they will
pay for physical health services.
So, if your insurance plan has no visit limit for outpatient physical health services, then there can be no limit on the number of visits for outpatient mental health and/or substance use services.
Protected by Law
The Mental Health Parity and Addiction Equity Act of 2008 improved access to mental health and addiction services for all Americans by requiring group health plans (with 50 or more participants) to guarantee that mental health or substance use disorder benefits are equitable to medical/surgical services.
The Affordable Care Act prohibits insurance companies from implementing lifetime limits and restricting annual limits on mental and substance use disorder benefits relative to physical health coverage. Also, individuals can no longer be denied coverage or have a plan canceled because of a preexisting behavioral health condition diagnosis.
Questions about your Benefits?
Your exact benefits depend on your state and the details of your plan. If you have questions about your plan, call your health insurance provider and request a “summary of benefits and coverage”. Your health plan must provide information about your mental health and substance use disorder benefits. Be sure to pay attention to the criteria the plan uses to decide if a service or treatment is medically necessary. If your plan denies payment for services, they must give you a written explanation of the denial and provide more information upon request.
Additional resources
Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS)
Stacy Grundy, MPH, CHES is a Certified Health Education Specialist and has a B.S. in Human Nutrition from the University of Illinois at Urbana-Champaign and a Master’s of Public Health in Health Promotion and Behavioral Sciences from the University of Texas School of Public Health. As a public health professional, her primary focus is the elimination of health disparities through policy, systems, and environmental changes.
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