Individual and small-group plans must cover mental health and substance use disorders (SUD) treatment, but with specific coverage requirements that vary by state. ^{These rules do not apply to plans that are} grandfathered or grandmothered under the ACA.

Total out-of-pocket costs and how those costs are distributed vary greatly from one plan to another. For example, some plans might cover various services with copays from the outset, while other plans might require you to meet your deductible (which could be thousands of dollars) before the plan starts to pay for any care. And as is the case for any type of care, total out-of-pocket exposure varies by plan.

Mental health parity rules apply to these types of plans.

Fully-insured large-group plans are plans an employer purchases from an insurance company ^{either directly, or through a sales agency. In most states, “large-group” means the employer has 51 or more employees, but there are some states where the threshold is 101 employees. (Under the ACA, this threshold was intended to be 101 employees, but the PACE Act reduced it to 51. States had the option to use the 101 threshold instead, and a few do so.)}

This type of plan must cover mental health and SUD treatment only if state regulations require it. These requirements vary from one state to another.

For plans that provide coverage for mental health and SUD treatment, out-of-pocket costs vary by plan, but there cannot be any dollar limits on how much the plan will pay for these services.

Mental health parity rules apply to these plans.

Self-insured plans, under which an employer uses its own money to pay employees’ claims, rather than purchasing coverage from an insurer, are not required by federal regulations to cover mental health care or SUD care, and states cannot set coverage mandates for self-insured plans. If a self-insured plan covers mental health or SUD treatment, the plan cannot limit how much the plan will pay for those services.

Mental health parity rules apply if the employer sponsoring the self-insured plan has more than 50 employees.

Medicare covers a wide range of mental health and SUD care, including both inpatient and outpatient care.

Medicare Advantage plans must cover at least the same services that Original Medicare covers, although out-of-pocket costs can be different. Medicare Advantage plans can also limit coverage to a specific network of providers, and can require prior authorization.

Federal parity rules do not apply to Medicare, but a separate law passed in 2008 reduced Medicare cost-sharing for outpatient mental health care to align it with cost-sharing for other kinds of outpatient medical care.

Medicaid is the largest payer for mental health services in the United States, ^{and various types of behavioral health care are encompassed under Medicaid’s mandatory benefits that all states must provide.}

As with other aspects of Medicaid coverage, specific benefits for mental health and SUD treatment vary from one state to another. But many states have federal Medicaid waivers that include various services to assist people with SUDs ^{Medicaid waivers are an option provided for in federal law that gives states flexibility to test innovative approaches to providing care.}

Mental health parity rules apply to Medicaid managed care plans, Medicaid alternative benefit plans (including the ACA’s expansion of Medicaid), ^{and the Children’s Health Insurance Program (CHIP).}

Short-term health insurance and coverage that is considered an “excepted benefit” do not have to cover mental health and SUD treatment.

Short-term health insurance policies are not considered individual health insurance, ^{are not regulated by the ACA, and are limited to total durations of no more than four months, including renewals. “Excepted benefits” include coverage such as workers’ compensation, fixed-indemnity plans, accident insurance, and critical illness plans.}

Mental health parity rules do not apply to short-term plans or excepted benefits coverage.

While many plans – including Marketplace plans and most employer-sponsored plans – cover mental health and SUD treatment, ^{short-term plans and excepted benefit plans typically do not provide these benefits.}

Prior to the ACA, mental health conditions and substance use disorders (SUD) were an obstacle to obtaining health insurance and often resulted in declined applications in the individual health insurance market. ^{But that is no longer the case, because of the ACA. The ACA banned the use of} medical underwriting in the individual market (where it was used extensively before 2014), ^{and eliminated pre-existing condition waiting periods for employer-sponsored health insurance.}

The ACA also allowed states to expand Medicaid to cover adults with income up to 138% of the federal poverty level, which 40 states and DC have done. ^{As of June 2024, nearly 21 million people are enrolled in Medicaid due to this expansion, resulting in better access to mental health and SUD treatment.}

The ACA also requires all non-grandfathered major medical health plans to cover various preventive care at no cost to the patient. Among the benefits included are depression screening and alcohol misuse screening for adults and adolescents, as well as autism screening and behavioral assessments for children.

Do ACA mental health coverage requirements apply to all health insurance?

The ACA requires individual and small-group health plans (with effective dates of Jan. 2014 or later) to cover essential health benefits (EHBs), with no annual or lifetime dollar limits. One of the categories that must be covered on all of these plans is “mental health and substance use disorder services, including behavioral health treatment.”

For perspective on the significance of this requirement, more than a third of non-group health plans didn’t provide any mental health benefits in 2013, and almost half did not cover SUD treatment. ^{(Pre-ACA coverage was better among employer-sponsored plans.)}

Within the ACA’s basic EHB framework, it’s up to each state to determine exactly what services must be covered. Each state has selected an EHB benchmark plan that details minimum coverage requirements for each EHB category. ^{So the specific mental health and SUD care that must be covered will vary from one state to another, depending on the state’s EHB benchmark plan’s coverage.}

Prescription drugs are also an EHB under the ACA. So all individual and small-group plans with effective dates in 2014 or later are required to cover prescriptions, including medications to treat behavioral health problems. But health plans set their own formularies – covered drug lists – within certain guidelines. ^{(Those guidelines include a requirement that the plan must cover at least as many drugs in each category and class of drugs as the state’s EHB benchmark plan – not necessarily the same drugs that the benchmark plan covers – or one drug in each category and class, whichever is greater.)}

Large-group and self-insured plans are not required to cover the ACA’s EHBs. But if they do, they must cover them without any annual or lifetime dollar limits on how much the plan will pay for an enrollee’s care.

Does mental health parity mean health plans must cover mental health?

No, mental health parity rules do not require health plans to cover mental health care. Learn more about mental health parity requirements.

As a result of the ACA, some health plans are required to provide coverage for mental health and SUD treatment. ^{And states can impose coverage mandates on plans that aren’t self-insured.}

Self-insured plans are subject to federal rules, but they are not subject to state insurance rules. There is no federal requirement that self-insured plans cover mental health or SUD treatment. ^{For plans that aren’t required to provide those benefits, mental health parity rules only apply if the plan opts to provide mental health and/or SUD benefits. And for self-insured plans, mental health parity rules only apply if the employer has more than 50 employees}

Does most health insurance cover therapy and medication?

As noted above, coverage requirements vary depending on the type of plan a person has. And as is the case for coverage of any type of healthcare, out-of-pocket costs and benefit specifics will vary from one health plan to another.

But most major medical health plans in the U.S. do cover mental health therapy ^{and mental health medications. Many plans will also cover telehealth therapy, although this varies by plan.}

A recent AHIP survey found that the majority of insured Americans who sought mental health care were able to obtain it without difficulty, and 90% were satisfied with the care they received. In addition, 60% reported that their mental health care was fully covered by insurance, and 33% reported that their mental health care was partially covered by insurance, while only 3% said that it wasn’t covered. ^{(Note that “covered” doesn’t mean the health plan pays the full bill, since enrollees have cost-sharing for covered services, in the form of deductibles, copays, and coinsurance.)}

But on the other hand, the American Psychological Association (APA) points to an analysis done by KFF and CNN, which found that a third of survey respondents were not able to access the mental health care they needed. Cost was the primary obstacle, as well as stigma and a shortage of mental health providers.

Compounding the shortage of providers is the fact that many mental health professionals do not accept insurance, ^{and psychiatrists are much more likely than other medical specialists to not accept new patients with either private health insurance or Medicare.}

So, if you already have a relationship with a mental health provider, you may have to switch to a different provider to utilize your health plan’s benefits, as your preferred provider might not accept your insurance. You can check with your plan to see if any out-of-network benefits are available. If so, you may be able to seek reimbursement from your plan for some of the cost of seeing a mental health professional who doesn’t accept insurance.

Do major medical plans cover substance use disorder treatment?

Although most major medical health plans will cover substance use disorder (SUD) treatment, the specifics vary by plan. ^{As noted above, the only plans that are required to cover SUD treatment are individual and small-group plans (under the ACA), or fully-insured large-group plans in states that require the coverage. Parity rules apply to far more plans, but again, that’s only applicable if the plan includes coverage for SUD treatment.}

Treatment needs vary depending on the patient, but can range from outpatient therapy to partial hospitalization to inpatient rehabilitation that can last anywhere from just a couple of weeks to more than three months.

Despite state and federal efforts to improve access to affordable SUD treatment, barriers remain. For example, some people may find that their policy doesn’t cover the type of inpatient care they need, or doesn’t cover medication-assisted addiction recovery.

And for Medicaid, which plays a significant role in covering SUD treatment in the U.S., there is significant state-to-state variation in the coverage provided and the care that enrollees receive.

As with other behavioral health care, it can sometimes be challenging for patients to find SUD practitioners who are in-network with their health plan.

If you need SUD treatment, you or a caregiver should check with your health plan to see what’s covered, whether prior authorization is needed, and what SUD treatment programs are in-network with your plan.

Do health plans cover eating disorder therapy?

Eating disorders are among the most serious behavioral health issues, ^{and a multifaceted treatment approach is often necessary.}

But while many health plans cover at least some aspects of eating disorder treatment, patients still face challenges in obtaining the care they need. For example, it can be difficult for a patient and their care team to prove to the patient’s health plan that a certain level of care – such as a residential program or inpatient treatment – is medically necessary, and health plans generally deny coverage if the care isn’t deemed medically necessary.

And some health plans will deny coverage based on metrics such as how much weight the patient has lost, without considering the full picture of the patient’s medical needs.

There are also gaps in the type of care covered by various plans, and some patients have difficulty finding in-network providers who can treat their eating disorder (as is the case for other types of behavioral health care).

Is marriage counseling typically covered by health insurance?

Most health insurance policies will not cover marriage counseling, as it’s not considered medically necessary treatment.

If one or both partners are diagnosed with a mental illness, such as depression or anxiety, health insurance will generally cover therapy to treat that condition. Depending on the circumstances, that might involve therapy where both partners are present, and it might include discussions about the marriage.

But if the purpose of the therapy is marriage counseling without a medical diagnosis, it’s unlikely that health insurance will cover the cost.

If your employer offers an employee assistance program, it may include access to a limited number of basic couples counseling sessions.

How can I find out if my health plan covers mental health treatment?

To find out whether your health insurance covers mental health treatment, you’ll need to confirm coverage details with your plan.

To see exactly what’s covered, you can read the summary plan description (SPD) that came with your policy, ^{or the policy documents you received if your policy doesn’t have an SPD. If you have questions about your benefits, you can contact the plan’s customer service department.}

Here are examples of questions you may want to ask your plan administrator before you seek non-emergency mental or SUD health care:

• How high will my out-of-pocket costs be for a primary care visit, specialist visits, other outpatient care, or inpatient care? Which services, if any, are covered with copays rather than a deductible?
• What mental health or SUD care – if any – requires prior authorization?
• Where can I see a list of mental health providers in my area who are in-network with the plan?
• Does the plan provide any out-of-network benefits?
• Where can I see the plan’s formulary (covered drug list)?
• Does the plan require step therapy for any covered behavioral health medications?