Mental Health & Substance Abuse Insurance Coverage

Source: HealthCare.gov

All Marketplace plans cover mental health and substance abuse services as essential health benefits.

Mental and behavioral health services are essential health benefits

All plans must cover:

Behavioral health treatment, such as psychotherapy and counseling

Mental and behavioral health inpatient services

Substance use disorder (commonly known as substance abuse) treatment

Your specific behavioral health benefits will depend on your state and the health plan you choose. You’ll see a full list of what each plan covers, including behavioral health benefits, when you compare plans in the Marketplace.

Pre-existing mental and behavioral health conditions are covered, and spending limits aren’t allowed

Marketplace plans can’t deny you coverage or charge you more just because you have any pre-existing condition, including mental health and substance use disorder conditions.       

Coverage for treatment of all pre-existing conditions begins the day your coverage starts.

Marketplace plans can’t put yearly or lifetime dollar limits on coverage of any essential health benefit, including 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 generally means limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The limits covered by 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

There are 14,500 (NIDA) addiction treatment facilities in the U.S. According to the Treatment Research Institute, 80% are outpatient facilities, 10% in-patient facilities, and 10% are methadone clinics.

Out-of-pocket expenses for in-patient substance use disorder treatment can range from $10,000 a month at standard substance treatment facilities to up to $80,000 a month at luxury substance treatment facilities. While free programs and public services are available through community health centers, for the average individual seeking treatment, speaking with your insurance provider and locating an in-network provider, where available, will be essential to the treatment and recovery process.