Is Therapy Covered by Insurance?

The Affordable Care Act requires plans offered through the health insurance exchanges to cover services for mental health and substance use disorders. Most health insurance plans cover at least some forms of mental health care, including therapy, but few health insurance plans are not required to provide any mental health benefits. In general, usually only treatments considered “medically necessary” by a mental health provider are covered by insurance.

If you are without health insurance, there are still affordable therapy options available to you. Our team at Mira can help you find low-cost therapists in addition to discounts off your prescriptions and flat fee doctor’s visits. Check out our other benefits today.

Is Therapy Covered by Insurance?

If you have health insurance, it is likely that your policy provides some level of coverage. However, your coverage will depend on the type of insurance you have.

Mental Health Parity Law

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (also known as the mental health parity law or federal parity law) requires insurance companies to charge the same copay for therapy as other medical offices visits. It doesn’t require coverage of mental health services; it prevents insurance companies from inflating the cost of seeing a mental health practitioner. The parity law also eliminated annual mental healthcare coverage limits.

The Mental Health Parity Law applies to Employer-sponsored health insurance plans; coverage purchased through the ACA health insurance exchanges, Children’s Health Insurance Program (CHIP), and most Medicaid programs. Some government plans, including Medicare, are exempt from the parity law. Additionally, some state government employee plans may opt out. However, the ACA doesn’t specify which types of counseling or therapy off-marketplace plans cover or how much of the costs. Many plans have some mental health coverage, but the benefits vary in provider networks, level of coverage, and type of mental health provider.

Therapy Coverage Through Different Health Insurance Plans

Depending on your health insurance plan, the cost of therapy will vary. Below, we outline coverage through each option.

Employer-Sponsored Health Insurance

Employer-sponsored health insurance plans usually cover therapy, but the level of coverage varies. It could be comprehensive coverage of all therapy services or only the minimum. If your company has more than 50 employees, your employer must provide health insurance which usually includes some level of therapy coverage. These types of plans vary greatly, so check out the specific benefits of the plan offered by your employer.

Obamacare Marketplace Plans

According to healthcare.gov, all health insurance plans bought on the marketplace must cover:

• Behavioral health treatment, including counseling and psychotherapy.
• Mental and behavioral health inpatient services.
• Substance use disorder or substance abuse treatment.

This means catastrophic bronze, silver, gold, and platinum plans will cover these services, even for preexisting conditions. The specific benefits may vary, so be sure to compare plans on the marketplace before enrolling. 

Outpatient Mental Health Therapy Benefits by Plan Metal Level: UnitedHealthcare, New York

Outpatient Mental Health Therapy Benefits by Plan Metal Level: Oscar, New York

The law also states marketplace health plans cannot deny you coverage or charge you more just because your mental health issue existed before you bought a plan, and they can’t place yearly or lifetime dollar limits on this type of coverage. Therapy coverage still varies from state to state and policy to policy.

CHIP (Children’s Health Insurance Program)

CHIP is subject to the Mental Health Parity Law and is required to provide parity protections for mental health and substance use disorder services. Most CHIP plans provide complete coverage of mental health services, including:

• Counseling
• Therapy
• Medication management
• Social work services
• Peer supports
• Substance use disorder treatments

Medicaid

Like CHIP, Medicaid is subject to the Mental Health Parity Law. While Medicaid plans vary from state to state, all state-run Medicaid plans must cover essential health benefits, including mental health and substance use services.

Medicare

Medicare Part B is an optional medical insurance plan that helps cover medical services like doctors’ services, outpatient care, and other medical services that Part A doesn’t cover. Part B helps pay for these outpatient mental health services:

• One depression screening per year. The screening must be done in a primary care doctor’s office or primary care clinic to provide follow-up treatment and referrals.
• Individual and group psychotherapy with doctors or certain other licensed professionals are allowed by the state where you get the services.
• Family counseling, if the primary purpose is to help with your treatment.
• Testing to find out if you’re getting the services you need and if your current treatment is helping you.
• Psychiatric evaluation.
• Medication management.
• Certain prescription drugs that aren’t usually “self-administered” (drugs you would normally take on your own), like some injections.
• Diagnostic tests.
• Partial hospitalization.
• A one-time “Welcome to Medicare” preventive visit. This visit includes a review of your possible risk factors for depression.
• A yearly “Wellness” visit. Talk to your doctor or other health care provider about changes in your mental health. They can evaluate your changes year to year.
• Part B also covers outpatient mental health services for the treatment of inappropriate alcohol and drug use.

Part B covers mental health services and visits with these types of health professionals: 

• Psychiatrist or another doctor
• Clinical psychologist
• Clinical social worker
• Clinical nurse specialist
• Nurse practitioner
• Physician assistant

In these settings:

• A doctor’s or other health care provider’s office
• A hospital outpatient department
• A community mental health center

Best Insurance Companies For Mental Health

Source: https://www.verywellmind.com/best-mental-health-insurance-5111859

Health Insurance Coverage for Therapy Frequently Asked Questions (FAQs)

Since health insurance coverage for therapy varies by type of insurance and plan, it is always important to check your benefits before making an appointment with a therapist to avoid surprise medical bills. You can always ask the therapist to check your coverage as well. Below we answer some common questions of therapy coverage.

Which mental health services are usually covered by health insurance?

When deemed “medically necessary” by a mental health professional, services that may be covered by insurance include:

• Psychiatric emergency services
• Co-occurring medical and behavioral health conditions, such as coexisting addiction and depression. This is often referred to as a dual diagnosis.
• Talking therapies, including psychotherapy and cognitive behavioral therapy
• Unlimited outpatient sessions with a psychiatrist, clinical social worker, or clinical psychologist. In some instances, your insurer may cap the number of visits you’re allowed annually unless your provider states in writing that they’re medically necessary for your care.
• Telemedicine and online therapy
• Inpatient behavioral health services are received in a hospital or rehabilitative setting. Your plan may limit the length of your stay or cap the dollar amount they’ll pay for your care per benefit period.
• Addiction treatment
• Medical detox services, including medications

How do I know if my health insurance covers therapy?

All ACA-compliant health insurance plans provide coverage for therapy but fall short of defining which type and how much therapy must be covered. To find out if your health insurance plan covers therapy, you have a few options:

1. Check your description of plan benefits on your online insurance portal.
2. Call your health insurance company directly.
3. Ask your therapist’s office to check for you.

To know how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

• Other insurance you may have
• How much your doctor charge
• Whether your doctor accepts assignment
• The type of facility
• Where you get your test, item, or service

A health plan is allowed to specifically exclude certain diagnoses, but these should be made clear to you in your plan’s description of mental health benefits. Again, if you are unsure about your coverage for therapy, contact your health insurance company before making an appointment.

What’s the difference between in-network vs. out-of-network therapists?

Depending on your health insurance plan, you will have access to specified in-network therapists and out-of-network providers that accept your health insurance. With an in-network therapist, you will pay a predetermined copay at the time of your appointment, and your insurance company will pay the rest. To know if a therapist is in-network, you can ask the office to check if they accept your insurance.

If you choose an out-of-network therapy provider, expect to pay more for the service since this is not something that your insurance will cover, similar to how medical health service coverage works. 

Why won’t my therapist accept my insurance, even though I have mental health coverage?

Mental health providers can choose whether or not to accept insurance. The reimbursement rate for mental health services is often low, so providers can make more money by only accepting patients who will pay out of pocket. This makes therapy unaffordable for many people, but before giving up on finding a therapist, ask if they charge on a sliding scale. Many therapists charge lower fees for people who make less money which can lower the cost of therapy without insurance.

Bottom Line

Therapy is an important part of well-being, and thankfully most health insurance plans offer some level of coverage for these services. If you want to talk with a professional, check your benefits or ask the therapists won't office to help you.

If you need help finding a mental health provider, our team at Mira can help you find one close to you. For an average of $45 per month, Mira can also allow you access discounted prescriptions, low-cost lab testing, and affordable urgent care visits for all of your health needs.

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255). You can call and speak with a counselor 24 hours a day, 7 days a week.