What is the Current Status Between Health Insurance and Mental Health Programs?

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Living with a mental health illness can lead to a lifestyle that is not highly favored and lowers a person’s quality of life. With proper treatment, though, almost any mental health condition can be properly managed. For many people, receiving the help they need to treat and manage their mental health is not the issue. After all, mental health services are offered at a wide variety of medical facilities. The primary issue for many people and their mental health is paying for the services they acquire, and with healthcare costs rising, the problem is becoming even larger.

What about you? Does your insurance cover mental health services?

The Affordable Care Act (ACT) has expanded mental health coverage to 62 million more Americans by building on the Mental Health Parity and Addiction Equity Act of 2008. The primary purpose of expanding this coverage is to ensure that mental health services are not only widely available, but affordable, too.

Although the ACA along with the Mental Health Parity Act have made it goal to expand mental health coverage, they still are overly-abundant with state-by-state disparities. One of the primary issues with expanding mental health coverage is deciding which instances actually fall under a mental health disorder. Take for example that a person comes into the ER for a drug overdose. Is the incident considered a mental health disorder, a suicide or a substance abuse issue? As you can see, insurance coverage and payment for mental health services becomes difficult to determine, especially when underlying issues are present, such as diabetes.

Here’s a closer look at the ACA and how it is helping people all across America enjoy better mental health coverage.

Does the ACA help people who suffer from mental health conditions?

Yes, the ACA has provided one of the biggest expansions for mental health services. It requires individual insurance providers as well as plans sponsored by employers to provide coverage for both substance abuse disorders and mental health conditions. For those who suffer from behavioral health challenges, rehabilitative services must be covered, too.

It is because of the new mandates that many health policies are now covering a wide variety of preventative services, such as screenings for mental health illnesses. Best of all, pre-existing mental health illnesses cannot cause an insurance provider to refuse coverage.

Does the ACA require all insurance plans to provide coverage for mental health benefits?

Essentially, yes. The following types of plans must provide coverage:

  • Marketplace plans
  • Employer-based plans
  • Individual health plans
  • Medicaid Alternative Benefit Plans
  • Children’s Health Insurance Program

All plans must provide coverage for essential health services, which fall into 10 categories, and it mental health illnesses are included as well as substance abuse disorders.

Is there a way to determine if your health insurance plan covers mental health services?

No matter your plan, the coverage must meet MHPAEA requirements, which means coverage must be provided for mental health services. This doesn’t mean that 100 percent coverage is provided, but these requirements definitely make mental health services more affordable. One of the best places to look to determine exactly what type of coverage is provided at your enrollment materials. Coverage levels for all benefits should be outlined.

How does the ACA influence insurance coverage summaries?

Another way that the ACA has influenced insurance coverage plans is by mandating that easy-to-understand summaries be provided with each plan. This allows policyholders to take better advantage of their health plans by simplifying coverage terms.

Is it against the law for a health insurance plan not to provide mental health coverage?

No, it is not against the law. There are some insurance plans are exempt from providing such extensive coverage. The parity law simply requires that if mental health coverage is provided, it must abide by the same requirements that physical health benefits abide by. If you have an insurance policy through a health exchange, then you can rest assured that coverage is provided for mental health services.

Do copayments apply to mental health services?

If your health insurance plan provides coverage for mental health services, your copayments and deductibles still apply. This means if you have a $1,500 annual deductible, then you will have to meet your deductible requirements before mental health coverage kicks in. Any co-payments that must be made must be paid, too.

Can insurance plans require different copayment amounts for mental health services?

Yes, your insurance plan can charge different copayment amounts. You may find that a trip to psychologist requires a copayment of $40, whereas a trip to your primary care physician requires only a $15 copayment. It is up to your insurance provider as to which copayment amounts go with each type of service.

What happens if a insurance provider limits the number of mental health services you can receive?

Take for example that you have recently been diagnosed with bipolar disorder and substance abuse issues, yet your insurance provider is telling you that you can only receive up to 12 therapy sessions each year. This type of situation is prohibited by the ACA. Your insurance company can put a strict number limit on appointments, but your case must be evaluated to see if further treatment is needed.

Let’s say you have recently been diagnosed with a disorder, and you have been instructed to take part in 52 outpatient counseling sessions, yet your insurance will only cover the first 20. After the first 20 sessions have been completed, your insurance must provide coverage for another assessment to take place. If it is determined that you still need to continue your counseling, then coverage must still be provided. If your insurance provider was to stop coverage before your psychologist thinks is necessary, then your insurance provider may be in violation of the law.

Do all mental health service providers have to accept insurance coverage?

Just because the ACA mandates that most insurance policies provide coverage for mental health illnesses, this doesn’t mean that mental health services provider have to accept the coverage. Because of this, many people are finding it just as difficult today to find and pay for mental health services as they did throughout the past decade. It is up to service providers as to which types of insurance coverage they accept, if any at all.

Tips for Using Your Health Insurance Coverage for Mental Health Services

Before you can use your insurance to pay for mental health services, you need to know exactly what is covered. If you are interested in checking into a residential facility for mental health services, simply contact the facility and see if it accepts your insurance. Make sure that when you speak to your provider that you ask about copayments and deductibles. You may have to pay for the services out of pocket, but you can at least use the funds to go toward your deductible, which will make additional services more affordable once your deductible has been paid in full.

Contact your insurance provider today to learn more about mental health services and your coverage limitations.

Please note, that state-funded insurance such as Medicare, Medicaid and SSI does not cover our services. To maintain the lowest rates for treatment with the highest quality of care, all of Pasadena Villa’s programs are primarily private payment.

The truth is that many private insurance companies do not cover treatment in residential mental health programs. However, we will work with you and your insurance company, on your behalf, to access  any possible insurance reimbursement for our services.

Our admissions team will coordinate the verification of your benefits to see if you have mental health coverage available and if our services will be covered under your specific policy. Once it is determined that your policy will cover our services, we will coordinate the pre-certification of your benefits as well as ongoing concurrent reviews for continued coverage during the course of treatment.

Our insurance staff and clinical team will work diligently to ensure all medical records clearly demonstrate medical necessity, which will significantly increase the likelihood of insurance coverage.

The Villa Orlando and Pasadena Villa’s Smoky Mountain Lodge are adult intensive psychiatric residential treatment centers for clients with serious mental illnesses. Our outpatient center is located in Raleigh, North Carolina. We also provide other individualized therapy programs, step-down residential programs, and less intensive mental health services, such as Community Residential Homes, Supportive Housing, Day Treatment Programs and Life Skills training. If you or someone you know may need counseling on mental health services, please fill out our contact form or call us at 407-215-2519 for more information.


If you’re ready to start your recovery, we’re here to help.

Contact us today.

Our treatment centers accept private payment, out-of-network benefits, and in-network benefits.

Our Admissions Team is available at 407.574.5190 to discuss your payment options.

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If you’re ready to take the next step in the recovery process for you or your loved one, the compassionate team at Pasadena Villa is here to help. Give us a call at 407.574.5190 or complete our contact form.

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