Individual and Family
Affordable Care Act (ACA) compliant plans are required to have mental health coverage due to provisions under both the ACA and the Mental Health and Addiction Parity Act (MHPA).
The Mental Health Parity Act (MHPA) was signed into law in 1996 and required that no annual or lifetime limits on mental health benefits could be any lower than any limits for medical or surgical benefits. However, as soon as this law was passed, insurers immediately found and took advantage of loopholes.
The MHPA was largely superseded in 2008 by the Mental Health Parity and Addiction Equity Act (MHPAEA), which extended the reach of the 1996 provisions and sought to close loopholes that were left open by the MHPA.
The MHPA required that no plans make the financial requirements on mental health coverage benefits (including co-pays, deductibles, or out-of-pocket maximums) or treatment limitations (such as caps on mental health service visits or hospital stays) more restrictive than the financial requirements or treatment limitations for medical or surgical benefits.
With ACA compliant plans, you can expect to have mental health services covered just as you can expect other services to be covered such as preventative care visits or hospital visits.
According to CMS.gov, under the ACA all compliant health insurance plans must cover ten essential benefits.
While all plans must cover these benefits in some way, keep in mind that plans can choose how they cover these benefits.
Additionally, under the ACA health insurance companies must cap customers’ out-of-pocket spending and must not place limits on annual or lifetime coverage for these services.
Has mental health always been covered?
Before the ACA, mental health coverage was lacking with most plans being sold on the individual and family health insurance market. Mental health coverage was much better with employer-sponsored insurance. Before the ACA, people could be denied coverage to those based on preexisting conditions – including mental health conditions. People with preexisting mental health conditions, faced difficulty finding health insurance coverage or finding coverage at an affordable rate.
Additionally, marketplace plans cannot put yearly or lifetime limits on coverage of any essential health benefit. This includes mental health and addiction services.
Because of the ACA, those who have a preexisting or a history of mental health conditions cannot be denied health insurance or charged at a higher rate than anyone else.
With an ACA compliant plan, you can expect to have mental health coverage. Your plan should cover some part of the expense of both mental health services and behavior health services. If you feel that your plan is denying you comprehensive mental health coverage you can talk with your plan provider or write a formal appeal.
All ACA plans must cover behavior health treatment, such as psychotherapy and counseling, as well as substance use disorder (also known as substance abuse) treatment. Additionally all plans must cover mental and behavioral health inpatient services.
Like with any other benefit, the higher metallic level you have the more coverage – including mental health coverage – you’ll get overall. Consider a higher metallic level (such as gold or platinum) if you require or expect to require a lot of or frequent mental health services.
According to a 2017 report by the Milliman firm, an office visit with a therapist is five times as likely to be out-of-network than a primary care appointment. You may want to opt for a plan type that doesn’t tend to have high out-of-network costs (such as a PPO plan) because your preferred mental health provider may be out-of-network or it may be difficult to find a provider you like in-network.
You can find plans that offer the mental health coverage you need on your state or federal marketplace, as well as eHealth.com! eHealth is the first and largest online health insurance brokerage. Start shopping for a plan that meets your mental health coverage needs with one of our licensed insurance agents or enter your zip code where prompted on this page to start comparing plans now!