November 14, 2013
The Affordable Care Act (signed into law in the United States in 2010 and effective January 1, 2014) resulted in the largest increase in mental health coverageincluding substance use disorder coveragein many years. Building on the Mental Health Parity and Addiction Equality legislation, this law expands insurance coverage and provides a number of additional mental and behavioral health benefits and protections.
The law requires health plans to cover preventative mental health services like depression screening and child behavioral assessments. In addition, most plans will not be able to deny coverage or charge more for coverage due to pre-existing medical conditionsincluding mental illnessunder the Affordable Care Act.
As of January 1, 2014, individual and small group health insurance plans must include coverage for essential health benefits in at least 10 categories. These categories include the following :
- Ambulatory patient services
- Emergency services
- Maternity and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
With regard to mental health and substance use disorder services, these health insurance plans must provide coverage requirements (e.g., co-pays, deductibles) and treatment limitations (e.g., visit limits) that are generally no more restrictive than coverage provided for other medical and surgical services. Regulations for mental health and substance use parity were established by the Mental Health Parity and Addiction Equality Act passed in 2008. The Affordable Care Act also requires health insurance companies to provide a clear summary of benefits.
Medicaid & Medicare
Children enrolled in a state Medicaid program are eligible for all medically necessary servicesincluding mental health services. Mental health services provided to adults who are enrolled in Medicaid vary from state to state. All state programs provide some adult mental health benefits and some provide substance use disorder services.
Under Medicaid, mental health services provided may include the following:
- Licensed clinical social work services
- Peer support
- Substance abuse treatment
Medicare also covers a range of mental health services.
- Medicare Part A covers inpatient mental health care (e.g., hospital room, meals, nursing care, supplies, related services)
- Medicare Part B helps cover office visits with a mental health care provider (e.g., psychiatrist, clinical psychologist, clinical social worker) and laboratory tests
- Medicare Part D helps cover prescription drugs used to treat mental health conditions. Each type of Part D plan has a list of covered medications.