Do Marketplace insurance plans cover mental health and substance abuse services?
Yes. All Marketplace insurance plans cover mental health and substance abuse services as an essential health benefit.
Mental and behavioral health services are essential health benefits
Health insurance plans available in the Marketplace must cover 10 categories of essential health benefits. One of these categories is mental health and substance abuse services. (Substance abuse is also known as substance use disorder.)
These services include behavioral health treatment, such as psychotherapy and counseling. They also include mental and behavioral health inpatient services and substance use disorder treatment.
Your specific behavioral health benefits will depend on the state you live in and the particular health plan you choose. You’ll see a full list of what each plan covers when you compare plans in the Health Insurance Marketplace.
Mental and behavioral health and pre-existing conditions
Marketplace plans can’t deny you coverage or charge you more just because you have a pre-existing condition. This includes mental health and substance use disorder conditions.
Coverage for treatment of pre-existing conditions begins as soon as your Marketplace coverage is in effect. There’s no waiting period for coverage of these services.
No lifetime or yearly dollar limits for mental health services
Marketplace plans can’t apply yearly or lifetime dollar limits on coverage of essential health benefits. This includes benefits for mental health and substance use disorder services.
Parity protections for mental health services
Marketplace plans must provide certain “parity” protections between mental health and substance abuse benefits on the one hand, and medical and surgical benefits on the other.
This means that in general, limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The kinds of limits covered by the parity protections include:
Financial, like deductibles, copayments, coinsurance, and out-of-pocket limits
Treatment, like limits to the number of days or visits covered
Care management, like being required to get authorization of treatment before getting it
More Answers: Mental Health and Substance Abuse Benefits
Can I keep my current mental health provider?
Possibly. Many insurance plans offer coverage through networks of hospitals, doctors, pharmacies, and other health care providers, including providers of behavioral health services. Depending on your Marketplace plan, you may pay less if you use network providers. Some plans will not cover services you get outside the plan’s network at all.
Before buying a Marketplace plan, check each plan’s network providers to see if yours are listed. If they’re not, check the plans’ out-of-network coverage policies.
Do job-based plans include mental health parity protections?
Some of them do.
The rights that apply to Marketplace insurance plans may not apply to some employer plans.
- Plans offered by small employers that are self-insured (these are plans that don’t buy insurance from an insurance company, but pay for employees’ health care costs themselves; they may use a health insurance company to manage claims and payments)
- Plans offered by employers that can show the federal government that the parity requirements have caused such a significant increase in plan costs that they qualify for a one-year exemption
- Plans offered by state and local government employers that are self-insured and choose not to apply the parity requirements, as long as they properly notify the federal government
- Plans that are grandfathered (generally those that have not changed their plan terms since March 2010)
- Retiree-only plans
These plans may cover mental health benefits they’re not required to. Check with your plan for details.
Does Medicaid cover mental health or substance use disorder services?
All state Medicaid programs provide some mental health and substance use disorder services. These services often include counseling, therapy, medication management, licensed clinical social work services, peer supports, and substance abuse treatment.
States determine which of these services to cover for adults. But Medicaid requires children get all medically necessary services, including mental health services.