Are Pre-Existing Mental Health Conditions Covered by Health Insurance?
By, BWellBStrong, Mental Health Advocacy and Awareness
Health insurance policies generally cover pre-existing mental health conditions. Insurance carriers must provide coverage to policyholders as long as the plan is purchased during an open or special enrollment period on the ACA exchanges. You may also find policies outside the ACA exchange that offer coverage for pre-existing mental illnesses. However, some aren’t ACA-compliant and don’t include pre-existing health conditions.
Knowing what’s considered a pre-existing condition in mental health, the types of treatments covered and the steps to qualify for coverage can help you find the most suitable policy for your needs.
What Are Pre-Existing Conditions?
Pre-existing conditions refer to medical and health issues known before or at the time of enrollment for an insurance policy. These include physical and mental conditions.
According to the latest data from the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 57.8 million adults in the U.S. have mental health conditions. However, 52.8% remain untreated. Related expenses may vary greatly depending on the condition and its severity — for some, it can be significant.
The passage of the ACA in 2010 removed pre-existing condition requirements health insurance providers used to impose. The first phase started during the same year. Insurers were prohibited from excluding pre-existing conditions from health insurance coverage for individuals under 19. At the start of 2014, the second phase was applied to include adults. Since then, insurance providers can no longer deny coverage to people with pre-existing conditions. This rule only applies to policies purchased during open and special enrollment periods.
Types of Pre-existing Mental Health Conditions
Generally, any mental health illness known to exist before applying for a health insurance policy can be considered a pre-existing condition. However, insurance companies may have a specific list of conditions they consider as pre-existing, especially if you purchase outside the open enrollment periods. These typically include anxiety and mood disorders, personality disorders, psychotic disorders and other mental and behavioral conditions.
Mental Health Condition
Other mental health and
Coverage for Pre-existing Mental Health Conditions
The ACA prohibits the exclusion of pre-existing conditions from coverages offered in ACA exchanges during the open or special enrollment period. The law also includes mental health and substance use disorder services as one of the 10 essential health benefits that all health plans in the Marketplace must cover. These include substance abuse treatment, behavioral health treatment and mental or behavioral health inpatient services. Specific benefits may vary depending on the state and policy.
Additionally, the Mental Health Parity and Addiction Equity Act (MHPAEA) prevents insurers offering health insurance for mental health and substance abuse treatment from providing less favorable limitations on such benefits like medical and surgical treatments.
Before purchasing a plan, you should understand your rights as a policyholder. Knowing this information can make it easier for you to navigate coverage for pre-existing mental health conditions.
If your policy covers pre-existing mental health conditions, your insurance provider should ensure:
Pre-existing mental conditions are covered, and limits aren’t allowed
Plans from the Marketplace can’t exclude pre-existing mental and behavioral health conditions from coverage. They also can’t impose dollar limits on covered benefits, including mental health services.
Higher premiums aren't charged for pre-existing conditions
Insurance carriers can’t deny coverage to any applicant due to a pre-existing condition, including mental illness. They also can’t charge higher premiums to individuals with existing health problems.
Plans must include certain essential benefits
Health insurance policies should cover the following mental and behavioral health services:
- Behavioral health treatment, such as psychotherapy and counseling.
- Mental and behavioral health inpatient services.
- Substance use disorder treatment.
Certain parity protections must be in place
Limits for mental health and substance abuse services coverage shouldn’t be more restrictive than the limits on medical and surgical services. Certain parity protections apply on the following limits:
- Financial: Coinsurance, copayments, deductibles and out-of-pocket limits.
- Treatment: Number of days and visits covered.
- Care management: Authorization requirements before getting treatment, for example.
Mental Health Treatments Covered by Insurance
Various factors affect the costs of coverage and treatment. You can anticipate spending more money on more involved treatments even if you have a high-quality health insurance plan. Your plan will need to abide by the following rules and cannot:
- Have a higher deductible for mental health and substance use services.
- Require a higher copay or coinsurance.
- Cap the number of times you can see a mental health provider.
- Charge higher prices for psychiatric or mental health-related medications.
- Limit the number of days authorized in a treatment facility.
- Require pre-authorization if such pre-authorization isn’t typically required to see other types of health care providers.
As a policyholder, you can expect your health insurance plan to cover the following treatments:
Annual wellness exams
Typically, health insurance plans cover an annual wellness exam for free. If you have a pre-existing mental health condition, you can take advantage of this opportunity and discuss your illness and treatment options with your doctor. Your doctor can also give you prescriptions during your wellness exam.
Counseling and therapy
Counseling and therapy, which can be done individually or in groups, refer to consultation with a therapist. A therapist may charge around $100–200 per session. Having insurance can lower the cost. Some mental health service providers may not accept your insurance plan.
Specializing in mental health, psychiatrists are doctors who can diagnose and treat different mental health conditions. They can also prescribe psychotropic medication. Plans with mental health care benefits usually cover psychiatric visits. Limits may vary per insurer but should follow parity protections.
Depending on your insurance policy, prescription drugs may be covered. However, not all medications may be included. Those commonly covered by health insurance for mental illness include anti-anxiety medications, antidepressants, antipsychotics and mood stabilizers. For a complete list, check the policy details.
Emergency room visits
Health insurance plans usually cover emergency room visits. However, you may need to pay out-of-pocket costs, such as coinsurance, copay and deductible.
In some cases, patients with more severe mental health conditions may experience episodes that require hospitalization.
Intensive outpatient program (IOP)
This comprehensive treatment targets behavioral and mental health conditions. Typically, an IOP offers a program for three evenings a week for about three hours, which is ideal for work and school schedules. There is also a partial hospitalization program (PHP), offered for five to six hours daily for five days with evenings at home.
Total expenses depend on the service provider and number of sessions. According to the American Addiction Centers, you may be charged $250–350 daily. In most cases, insurance plans covering treatments for mental health conditions and substance abuse will cover most of the cost of these programs. You will still have to pay your copay, coinsurance and deductible.
Steps to Qualify for Mental Health Benefits and Coverage
Knowing how to qualify for the right benefits can help you better navigate health insurance and ensure you purchase proper coverage.
- Review the health plan: Make sure your health plan is ACA-compliant. If not, check if it offers coverage for pre-existing mental health conditions.
- Check the procedures and requirements: Qualification requirements vary per insurance carrier, especially those outside the open enrollment period. For instance, some companies may require medical underwriting. This is when your medical history is examined to evaluate your coverage application.
- Disclose your condition: When buying a health insurance policy, it may be best to be honest about pre-existing conditions. This will help ensure financial protection. Remember, no insurance company can access your medical reports without your permission.
Insurers can’t refuse coverage of pre-existing mental health conditions. The ACA offers protections against possible health insurance discrimination. It may be wise to inform them of your illness. This way, you can ensure suitable coverage. This may also prevent potential issues due to non-disclosure.
Can Insurers Deny Coverage for Pre-Existing Mental Health Conditions?
Health insurance providers can’t deny people with pre-existing mental health conditions. Under the ACA, all individuals are eligible for coverage regardless of whether they have an illness prior to purchasing the plan. It’s illegal for insurers to refuse if the policy is from the Marketplace during the open enrollment period.
Certain exceptions apply. This rule doesn’t apply to those who enrolled in a plan before 2010. Insurance providers that the ACA doesn’t regulate may also refuse coverage.
Health Plans Excluding Pre-Existing Mental Health Conditions
Two types of health insurance policies don’t follow the ACA rules: Grandfathered and short-term medical policies. If you have any of these plans, clarify what your insurance covers, as it may not include pre-existing mental health conditions.
Grandfathered medical plans
If you got your health insurance plan on or before March 23, 2010, it’s considered a grandfathered policy. Group plans created during the same period, regardless of when you joined, are also grandfathered.
Short-term medical policies
These temporary plans provide health insurance coverage. These are typically cheaper but have less coverage. Depending on the carrier, people with pre-existing conditions may not qualify for this type of insurance.
If you happen to have a grandfathered or short-term medical policy and you want to get coverage for your pre-existing mental health conditions, you may want to consider switching to a Marketplace plan during the open enrollment period. The open enrollment period for the next year starts on November 1 of every year.
People who have had certain life events, such as getting married, having a child, moving to a new area, losing health coverage or having a low household income, may be eligible to enroll during the Special Enrollment Period. This is 60 days before or following the said life event.
What to Do if You’ve Been Denied Coverage or Benefits
If you think you’ve been wrongly denied insurance coverage or benefits for your mental health illness, behavioral condition or substance use disorder, you may appeal the insurance company’s decision. You can start the process by completing the following steps.
Consult your documents
The first thing you need to do is review your plan. Check your records and look for your insurer’s appeal process.
Go to your state’s insurance commissioner’s office
If reporting a violation to your insurer doesn’t work, you can take your complaint to your state’s insurance commissioner’s office.
Call the Center for Medicaid and Medicare Services (CMS)
The CMS enforces parity laws. You can report any insurance provider that violated parity requirements through their toll-free number (877) 267-2323.
File a complaint with the Department of Labor
If an employer’s plan covers you and they don’t follow parity requirements, file a complaint to the Department of Labor. You can do this online by completing the agency’s Contact Us form. You may also call the Employee Benefits Security Administration (EBSA) at (866) 444-3272.
Where to Get Insurance Coverage for Pre-Existing Mental Health Conditions
One of the challenges people with pre-existing mental health conditions face is finding the best health insurance policy. With many options available, it may be a bit difficult to determine the right plan.
Understanding common sources of health insurance — ACA Marketplace, employer plans, private non-ACA-compliant policies, Medicaid, Medicare and Flexible Spending Accounts — can help you with your search for a health plan.
ACA Marketplace insurance
Plans purchased through ACA exchanges, whether through an agent or directly, ensure mental health and substance use treatment coverage. You can get this during the open or special enrollment period.
Many employers offer health insurance plans to their employees. Check with your company’s human resources department if they offer this benefit and how you can be covered. Ask them about out-of-pocket expenses and coverage inclusions. They may also give you a list of providers accepting your insurance.
You can get insurance outside the ACA exchange. Many private insurers offer health plans. However, they may not be ACA-compliant. This means you should check if pre-existing mental health conditions will be covered.
Medicaid, a federally-subsidized program for low-income individuals and households, is administered by states. That means enrollment and specific guidelines may vary per location.
Medicare is a government-funded program for individuals aged 65 or older. This may provide certain mental health benefits like counseling, therapy and screening. Specific coverages may vary depending on the type of Medicare you buy.
Flexible Spending Accounts
Some employers offer flexible spending accounts (FSA), a tax-advantaged account that can be used to pay medical expenses. You’ll have to contribute to the FSA to access benefits.
How to Find the Right Coverage
There are various factors to consider when choosing a health plan. What may seem like the right coverage for one person may not be adequate for another. Personal circumstances and needs are crucial in determining which plan you should get.
When looking for a policy, it’s best to compare quotes and offers from different insurance providers. This helps you find the most suitable policy for your needs.
Not all policies cover pre-existing mental health conditions. So, make sure you read the policy documents thoroughly. If you have questions, clarify them with your agent or insurer.
Prepare documents in advance
Insurance companies may require you to submit certain documents. Before applying for coverage, check all requirements first. Gather all necessary documents.
Discuss your needs
It’s best to talk to your insurer about your insurance needs. They can help you choose the right plan. You may also check with them to see if you’re eligible for any money-saving opportunities the company offers.
How to Get Mental Health Care if You’re Uninsured
Mental health care can be expensive. People suffering from certain conditions may have difficulty accessing necessary treatments. This is especially true for those who don’t have health insurance.
According to Mental Health America, over 5.5 million U.S. adults with mental health conditions are uninsured. Fortunately, there are ways to find affordable medical care.
Ask about discounts
Some therapists may offer a sliding scale to their patients. It would be good to ask your therapist if you can get discounted sessions.
Contact a social worker
You might want to start your search through your state’s Department of Public Health or a similar agency. They may be able to connect you with low-cost or free community-based clinics and services in your area. Social workers may also help you qualify for assistance and government programs.
Contact an online therapist
Conduct an online search for virtual therapists. Typically, they offer services through a convenient online meeting environment you can access from your home or office.
Contact the National Association of Free and Charitable Clinics
This nonprofit organization helps medically underserved people access health care services, which may include mental health and addiction treatment.
Did you know that reduced-cost therapy is available at training institutes? Advanced students, under the supervision of an established therapist, can provide affordable services.
Expert Insight on Pre-Existing Mental Health Conditions
Navigating health insurance and ensuring coverage for pre-existing mental health conditions can be overwhelming. One of MoneyGeek’s industry experts shared their insight which may help you decide on your best course of action.
- How do I know when I should see a mental health professional? How can I determine the right kind of therapist?
- What alternatives are available for mental health conditions not covered by health insurance?
- Are there programs, aids or resources to help people with pre-existing mental health conditions pay for treatment? Can you share some of them?
- How much can I expect therapy to cost without insurance?
- What’s a sliding scale?
- Can I barter for therapy?
- When do I need to go to the hospital?
- I’m worried about a loved one who is dealing with mental illness. What can I do to help?
BWellBStrong, Mental Health Advocacy and Awareness
Integrative Mental Health Physician and Psychotherapist
Resources can provide helpful information when looking for mental health care, treatment and coverage. To help you get started, MoneyGeek compiled some of them.
- American Academy of Child and Adolescent Psychiatry: This online finder connects you with a child and adolescent psychiatrist.
- American Psychiatric Association Foundation: Use the online search tool to find a psychiatrist offering treatment and diagnosis in your state.
- American Psychological Association: Input your location and find a psychologist offering services near you.
- Depression and Bipolar Support Alliance: Find a support group for people with depression or bipolar disorder. There are also peer-run online support groups for free.
- FindTreatment.gov: Enter your zip code and find a treatment facility near you.
- Make the connection: Find inspiration from stories of veterans and their loved ones as they share the challenges they faced and their road to recovery. Learn about the signs and symptoms of various behavioral and mental health disorders.
- National Alliance on Mental Illness: Access various infographics and fact sheets about mental health illness, parity law and access to care.
- National Empowerment Center: Find links to various resources, including a listening line and phone-based support groups.
- National Institute of Mental Health: Use these contact numbers if you or a loved one requires immediate help. Find a health care provider providing treatment for mental illnesses.
- Samaritans: Find suicide prevention services. Call their 24/7 helpline or text 988.
- Supportiv: This peer-support network helps you connect with people who may be experiencing the same struggles as you. The network is open 24/7 and promises trained moderators.
- U.S. Department of Health and Human Services: Under the Health Insurance Portability and Accountability Act (HIPAA), learn more about your rights and privacy rules on health information.
- American Addiction Centers. "The Cost to Attend an IOP." Accessed May 8, 2023.
- Centers for Medicare & Medicaid Services’ Center. "The Mental Health Parity and Addiction Equity Act (MHPAEA)." Accessed May 5, 2023.
- HealthCare.gov. "Health Benefits & Coverage." Accessed May 5, 2023.
- Mental Health America. "2022 The State of Mental Health in America." Accessed May 4, 2023.
- Psychology Today. "Cost and Insurance Coverage." Accessed May 8, 2023.
- Substance Abuse and Mental Health Services Administration. "Highlights for the 2021 National Survey on Drug Use and Health." Accessed May 4, 2023.