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As reported on HealthCare.gov, mental health and substance abuse services are covered as essential benefits under all Marketplace plans. These plans are required to provide “parity” protections between medical and surgical benefits and mental health and substance abuse benefits. What this means, generally, is that the limits cannot be more restrictive for one than the other. This parity applies to:
While the existence of physical health conditions can be established with concrete medical evidence, diagnoses of mental health conditions are much more subjective, based as they are on the opinions of mental healthcare professionals and science lacking in physical proof.
A Marketplace health plan cannot deny you coverage or charge you more for health insurance because you have a pre-existing condition. This rule also applies to mental conditions and substance abuse. In addition, these plans are prohibited from placing an annual or lifetime dollar limit on any coverage that is considered to be an essential benefit. Under current law, this includes mental and substance abuse disorders.
Federal law requires all Marketplace plans to cover:
Private health plans can vary in their mental health benefits. They typically offer fewer mental health services than Medicaid or public mental health programs. Many cover:
Medicare covers a variety of mental health services, as follows:
Many people receive Medicare benefits through a Medicare Advantage Plan. If you are enrolled in a Medicare Advantage HMO, PPO, or another health plan, check the membership materials for details about the plan’s mental health benefits.
Medicaid programs may vary from state to state. All programs provide some mental health services, which may include counseling, medication management, therapy, peer support, social worker services, and substance abuse treatment. Coverage for new Medicaid adult expansion populations must include essential health benefits, which have been determined to include mental health and substance abuse treatment. It must meet the same parity requirements as health plans in the Marketplace.
If you are unsure about what mental health services your health plan should provide, speak with our knowledgeable agent. We can review enrollment or other materials for your plan to help you find out about the coverage levels for various services.
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