March 21, 2024

Behavioral and Mental Health Insurance: What’s Covered, How It Works, and Frequently Asked Questions

Behavioral and Mental Health Insurance: What’s Covered, How It Works, and Frequently Asked Questions

It can be frustrating to not have the right kind of insurance in a crisis or when treatment is crucial. That’s true whether you have a physical medical need or a mental health disorder.

Many patients wonder if mental health and substance use treatments are covered by insurance.

In this guide, we’ll discuss what mental health insurance is and what it covers. We’ll also answer some frequently asked questions, so you can be sure you’re fully covered, no matter what your mental health needs may be.

Table of Contents

Is Mental Health Covered by Insurance?

Yes. Beginning in 2014, the Affordable Care Act required insurance companies to provide coverage for mental health and substance use disorders. 

Mental health and substance abuse treatments are considered one of the 10 essential health benefits that must be offered to each person in individual and small-group health insurance markets.

Though a patient may be covered under mental health insurance, it’s important to be aware that the insurance company will authorize the level of care they deem appropriate based on a behavioral health clinic’s assessment.

What Is Behavioral Health Insurance?

Behavior health insurance is coverage for the treatment of mental health, substance use, and eating disorders. Treatment may include rehabilitative and habilitative services. Mental health insurance plans must comply with certain requirements in the Mental Health Parity and Addiction Equity Act (MHPAEA), which means that mental health and substance use coverage cannot be more restrictive than other medical coverage.

Healthcare plans in the federal Health Insurance Marketplace are required to provide the following 10 essential benefits:

  1. Wellness and disease management
  2. Prescription drugs
  3. Hospitalization
  4. Laboratory services
  5. Emergency services
  6. Maternity and newborn care
  7. Children’s care, dental, and vision
  8. Rehabilitation and habilitation
  9. Mental, behavioral health, and substance use care
  10. Outpatient clinic services

Private insurance plans differ in the medical and health benefits they offer — usually offering more limited mental health services than public mental health insurance programs.

Private mental health plans may cover services like:

  • Emergency care
  • Prescription drugs
  • Outpatient mental health treatment
  • Partial hospitalization
  • Inpatient hospitalization

Behavioral and Mental Health Insurance: What Exactly Is Covered?

The specifics of coverage may change depending on the state you live in or the health plan you choose.

Some of the services a mental health insurance plan may cover include:

  • Therapy — Counseling, cognitive behavior therapy, and dialectical behavior therapy
  • Partial hospitalization — Treatment during daytime hours without an overnight stay
  • Inpatient hospitalization — Hospital stay with continuous care
  • Substance use treatment — Counseling, 12-step programs, and medication management
  • Emergency treatment — Crisis intervention and overdose treatment
  • Medication — Partial or complete coverage

Depending on health plans, the following services may not be included in mental health insurance:

  • Services that are not medically necessary
  • Experimental treatments
  • Genetic testing
  • Services that are not clinically necessary or involved with a diagnosis

Common Mental Health Insurance Benefits

In addition to the coverage provided by mental health insurance plans, access to mental health insurance also brings other advantages, like:

  • Access to licensed mental health providers.
  • Mental health and follow-up services.
  • Consultation and referral services.

Access to the Behavioral Health Network of Licensed Mental Health Providers

When people struggle with mental health issues or substance use, it’s critical to receive care from a qualified mental health provider. 

With mental health insurance, you can locate providers trained to treat you with skill and knowledge. 

Licensed mental health care providers can include:

  • Therapists
  • Counselors
  • Psychologists
  • Psychiatrists
  • Clinicians
  • Addiction counselors
  • Social workers; and
  • Mental health nurse practitioners

Though you may not always need a referral to see one of these mental health care professionals, your primary care physician may be the best person to help you find treatment.

Needing a referral may depend on what the mental health insurance requires. The specialists themselves — a psychiatrist, for example — may be the ones requiring the referral. 

Visiting your primary care physician is a great first step to obtaining the referral you need.

Mental Health Services and Follow-Up Case Management Services

Mental health insurance is also beneficial because of the varied services it provides for both direct and follow-up care.

Though services vary depending on the type of insurance plan, common mental health services include:

  • Individual and group psychotherapy
  • Medication
  • Counseling
  • Cognitive and dialectical behavior therapy
  • Hospital or residential treatment
  • Electroconvulsive (ECT) and eye movement desensitization and reprocessing (EMDR) therapy

After a patient has been involved in extensive therapy or hospitalization, follow-up may be required. These types of case management follow-up services are often covered by mental health insurance.

For example …

  • Attending an outpatient program
  • Visiting with a psychiatrist regarding medication; or
  • Taking part in outpatient psychotherapy

… may be types of outpatient treatments provided for maximum follow-up management.

Consultations, Referral Services, and Outpatient Services

Beyond inpatient services, counseling, therapy, and medication treatment, mental health insurance can be beneficial when outside services and referrals may be the next step in a patient’s treatment.

Perhaps a patient experiences extreme anxiety or depression. A consultation with a mental health practitioner may be necessary to gauge the patient’s needs and treatment.

Behavioral health care providers may also refer patients to:

  • Local community support groups
  • Behavior coaches; and
  • Online resources

Many times, ongoing outpatient services are the most appropriate treatment and may include different types of therapy or counseling.

Mental health insurance may cover these types of consultations, referrals, and outpatient services.

Whether insured by a public or private insurer, patients benefit when their behavioral health provider’s system runs smoothly and seamlessly.

To do that well, providers and clinics need the best tools to manage the many tasks involved — and that includes systems for easily managing referrals and other outpatient services. 

Ritten is an Electronic Medical Record (EMR) software with the essential tools to help behavioral health care providers successfully and efficiently manage the day-to-day processes and systems of their clinics.

Common Substance Use Benefits

Mental health insurance also covers substance use disorders and access to mental health insurance provides various benefits, like:

  • Inpatient and outpatient treatment.
  • Coaching and support programs.
  • Referral services and online resources.

Inpatient and Outpatient Treatment Services

Substance use disorders may require intensive treatment in the form of inpatient or outpatient services.

Inpatient treatment is the most intense and requires the patient to admit themselves to a center for residential treatment. 

Designed for those with serious disorders or addictions, patients receive around-the-clock care and support.

Outpatient care provides programs and treatments that are less restrictive and can allow patients to work or attend school. Outpatient programs can include:

  • Partial hospitalization programs (PHPs); and
  • Intensive outpatient programs (IOPs)

PHP programs usually involve five to six hours of treatment a day, while IOPs are less restrictive, usually involving three hours of treatment several times a week.

Depending on the type of insurance plan, there may be some parts of outpatient care that aren’t covered.

For example, a patient involved in a PHP who also wants to be involved in sober living may need to contribute financially. An insurance plan may pay for the PHP portion of treatment, and the patient may need to pay out of pocket for the sober living service.

Additionally, outpatient and inpatient services can be combined with follow-up case management services if needed. 

Personalized Coaching and Support Programs 

Whether a patient’s treatment involves inpatient or outpatient services, many who struggle with a substance use disorder can find help and support through personalized coaching and support programs.

Some mental health insurance plans may cover the costs of these types of services, which may include:

  • Therapy
  • Personalized coaching
  • Recovery specialists
  • Support programs
  • And more

Because these services take a patient’s schedule and life challenges into account, they can be personalized to meet individual needs.

Recovery specialists and coaches are trained to understand a patient’s needs and help them find the service and support that’s most appropriate. Those with mental health insurance that covers these services benefit from increased confidence, motivation, and access to necessary resources.

Referrals to Local Community Support Groups, Behavioral Coaches, and Online Resources

In addition to the resources above, patients with mental health insurance can also benefit from referrals. Finding substance use disorder professionals and support resources can be a challenge. Access to mental health insurance can make that process much easier.

Support groups fall into different categories, including:

  • Psychoeducational groups
  • Skills development groups
  • Cognitive-behavioral groups
  • Support groups; and
  • Interpersonal process groups

Finding the group that is most suited to your needs is possible with referrals through a mental health insurance plan. 

If one-on-one treatment is preferred, there are also resources available to find behavioral coaches.

Online resources abound, and patients can be connected to online resources categorized by:

  • Population — i.e., women, teens, or seniors
  • Type of addiction — i.e., alcohol, cocaine, or tobacco
  • Use for family members

Behavioral and Mental Health Insurance FAQs

What Role Does an Insurance Company Play in the Level of Care a Patient Receives? 

Insurance companies carry a lot of weight when it comes to the level of care a patient receives.

Typically, a patient will visit a clinic or provider for an assessment, and the provider will recommend a treatment plan. The provider then submits their recommendation to the mental health insurance company. The company will then authorize the recommended treatment, deny the treatment plan, or authorize an amended plan.

For example, after an assessment, a clinic may recommend a 30-day residential treatment plan. After submitting the plan to the mental health insurance company, they may only authorize 15 days of residential treatment or 30 days of partial hospitalization.

There is typically a treatment process of utilization review that may allow treatment to be extended. For example, if 15 days of residential treatment was approved by the insurance company, the clinic may send a review on day 13 requesting additional treatment. The insurance company may or may not approve the request, however.

Can You Get Mental Health Care Without Insurance?

Yes, mental health care is available without insurance, but it may be challenging to find, depending on where you live. However, all licensed medical providers are required to make emergency care available, but it may be costly.

Some other options for obtaining mental health care if you don’t have insurance include:

  • Medicaid
  • Free or low-cost healthcare options
  • Community mental health care centers
  • University hospitals that provide free or discounted services given by students in a teaching program

For additional information and resources for those without healthcare, visit the Substance Abuse and Mental Health Services Administration (SAMHSA) or the National Alliance on Mental Illness (NAMI).

What Should I Look for When Searching for a Mental Health Provider?

Looking for a provider that is in the insurance company’s network is the most important step

When patients choose an in-network provider, they’ll be assured that their covered expenses will be taken care of. Choosing a provider who is not in the network means patients can’t be sure of what will be covered and what won't, which may leave them paying extensive out-of-pocket costs.

When choosing a mental health provider, also consider the following:

  • Network size — Larger networks provide a larger selection of mental health care providers.
  • Virtual appointments — Being able to receive treatment from anywhere is a plus, and many mental health care providers include virtual services.
  • Covered services — Compare the services that insurance plans cover, paying attention to those that are most pertinent to your treatment needs.
  • Referrals — Find out if referrals are necessary.
  • Resources — Look for providers who include free resources.

Own a Behavioral Health Clinic? Utilize an Intuitive Scheduling Software for Your Patients

If you are one of the many clinics that provide essential mental health care to your patients, you know how important it is for your processes to run smoothly to ensure the best care for your patients.

Ritten’s EMR software can help with everything — from managing documentation and schedules to monitoring outcomes and managing medication.

Because we believe the future of healthcare is data-driven, we strive to create the best software tools to capture data and drive better outcomes.

If you’re frustrated with your current EMR or looking for something to help your clinic run seamlessly, book a demo with Ritten today.

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