Hi all, Joelle here. This topic is more my specialty, so I hope it’s okay if I share some info with you today about mental health services under the Affordable Care Act. Sorry, I’m not as good as Duff at putting things into plain language, but I will try my best! Also, insurance is pretty complicated, so I’m trying to keep this specifically to mental health services under the Affordable Care Act. I will link to some other resources so that you can do more research on your own.
What is the Affordable Care Act?
The Affordable Care Act, also known as the ACA or Obamacare, was a piece of legislation that President Obama signed into law in 2010, with major components enacted in 2014. It overhauled individual insurance markets and mandates while expanding Medicaid and Medicare and adding requirements to employer provided plans.
The general essence of the ACA was to ensure that insurance companies offer plans to everyone, while charging the same rates regardless of sex or pre-existing conditions. All people in the United States are now mandated to have insurance under Obamacare, and are guaranteed a list of “essential health benefits” in return. In addition, those who purchase health insurance in the individual exchanges are offered subsidies based on their income and other factors, though these subsidies are not guaranteed anymore under the current administration.
What is open enrollment?
Open enrollment is the period of time every year in which people can opt-in to individual insurance plans, though those who experience a major life event such as marriage, birth of a child, or job loss, can change or purchase insurance throughout the year.
For 2017, the open enrollment period is November 1 to December 15, which is shorter than open enrollment in years past.
How Do I Enroll in a Plan?
If you are eligible for a subsidy through the government, you will want to purchase your coverage in an exchange. Most states have their own exchanges set up. You can find out what exchange you will use to purchase coverage here.
You can also purchase coverage directly through the insurance companies, though you won’t be able to get a subsidy for it.
As of November 1, 2017, what mental health services are covered under the ACA?
All health insurance plans are required to offer mental health coverage, including behavioral health treatment, such as psychotherapy and counseling, inpatient services, and substance abuse treatment. In addition, most plans also offer preventative mental healthcare. The Affordable Care Act also removed lifetime limits, which means that you can’t “run out” of coverage for these, or any other, services
These terms are supported by the Affordable Care Act and in conjunction with the Mental Health Parity and Addiction Equity Act, which was passed in 2008. Another condition under these acts is parity. This simply means that insurance companies must treat mental health and medical benefits the same. For example, they cannot charge more for copays or deductibles for mental health services, or limit your access to these services while allowing greater access to medical or surgical services.
Note that parity requirements do not apply to employer plans with less than 50 people, Medicare, and state government employee plans.
Should I worry about a pre-existing condition if I’ve been diagnosed with a mental illness?
No. A major component of the ACA is that pre-existing conditions MUST be covered, including mental health and substance use disorders. Though you may see some talk about Congress getting rid of this mandate, you cannot be denied health coverage in 2017 for 2018 if you have a pre-existing condition.
What should I look for in healthcare plans for mental health?
All mental health services will be listed in the coverage summary for your insurance plan (you can see an example here). You will want to look at your general terms, including your deductible/out of pocket maximum, and copays. From there, take a look at the mental health section. It should give you an idea of what is covered before your deductible, what your copayments are for mental health services, and what coverage is for in and out-of-network providers.
The information in this summary is going to be very general. For the most part, insurance companies may require prior authorization before seeking any type of specialty treatment. This means that your doctor will have to refer you to mental health services. Depending on the type of coverage you have, your insurance will likely require you to meet your deductible before benefits for mental health services kick in. This wouldn’t be any different than deductible requirements for any other type of health services (parity), and should also be specified on your coverage summary. You can read more about deductibles here.
Will I Get to Choose my Therapist?
This one depends. When your insurance plan requires that you use in-network providers, you will either be assigned a therapist or be given a list to choose from. Even if you are assigned a therapist, however, you can always request a change through your insurance company. You may encounter some resistance about making a change depending on your insurance company, but it is a right that you have.
If you have a preferred therapist, you can ask if they accept your insurance plan. If not, there may be an option to get reimbursed from your insurance company, but this is something that you will want to find out prior to choosing a plan. If your insurance company requires you to have a specific CPT code to check on reimbursement for mental health services, a list of common codes can be found here.
Do Medicaid/Medicare cover mental health services under the Affordable Care Act?
In general, yes. The requirements for mental health services covered by Medicaid and Medicare vary, however, so it would be best to look into information that addresses those programs specifically. You can visit the Medicaid website here and the Medicare website here. Also, Medicaid benefits vary by state, so you may want to check into your specific state’s website for more information.
About Duff the Wife
Joelle Duff is Dr. Duff’s high school sweetheart, baby mama, and wife of seven years. She is a political activist and the official “Creative Director” for Duff the Psych (that’s the best term they could come up with). Basically, she keeps Duff on track and manages the website and branding. In addition, she has her own brand, Joelle Charming, and is an experienced wedding planner in the Santa Barbara area.
In 2014, Joelle was diagnosed with Bipolar II and hospitalized for suicidal thoughts. She has been inspired to share her own mental health journey, and works with Dr. Duff to promote mental wellness and reduce the stigma around mental illness.