Essential Health Benefit Spotlight: Mental Health Care

Health Insurance

May 12, 2020

Nearly 20% of American adults experience a mental illness — that’s one out of every five adults. Even more telling, about half of adults (46.4%) in the U.S. will experience a mental illness at some point in their lives. And the stat isn’t much better for youth. Among kids aged 6 to 17, about 17% have a mental health disorder.

If you suffer from a mental illness or mental health disorder — or you know someone who does — then we don’t need to throw percentages at you.

Living with a condition that affects how you think, feel, process the world and interact with others can be everything from inconvenient to debilitating. 

Mental health conditions come in different packages with different diagnoses: depression, bipolar disorder, schizophrenia, anxiety disorders, ADHD and PTSD, to name a few. 

And just because it’s called a “mental health condition” doesn’t mean it’s all in your head. It also affects your physical health. People with serious mental illnesses are at higher risks for chronic diseases, including diabetes and cancer. In fact, 1 out of every 8 emergency room visits in the U.S. is related to a mental and/or substance use disorder.

In short, people need mental health care. 

Not only do Americans need access to treatments, but we also need coverage for therapies designed to address mental health problems. Unfortunately, not enough people are getting the help they need, and that may come down to health insurance and cost. Less than half (43%) of adults with a mental illness will get therapy in a given year.

But it doesn’t have to be that way.

Did you know that mental health care is a required benefit for major medical insurance plans?

Thanks to the Affordable Care Act (ACA or “Obamacare”), signed into law in 2010, major medical plans must cover mental health care as part of the law’s “10 essential health benefits.” And there are other rules about mental health care coverage, designed to help people get the care they need when they need it.

Whether you’re insured or not, here’s what you need to know about the mental health care benefit under Obamacare.

10 Essential Health Benefits

The Affordable Care Act requires comprehensive plans sold on or after March 23, 2010 to cover 10 essential health benefits. They are:

  • Preventive care
  • Mental health care
  • Maternity care
  • Prescription drugs
  • Hospitalization
  • Outpatient services
  • Emergency care
  • Pediatric care, including dental and vision
  • Lab services
  • Rehabilitative care and equipment

Now, these are categories of benefits. Each type of essential benefit covers a broad range of services. For example, outpatient care covers many things, including minor surgeries, trips to the doctor for stitches or a UTI, and other services you get outside of a hospital. 

Copays, specific plan limits and other terms depend on the health plan you have. And with the exception of preventive services, these essential benefits still require cost sharing — i.e., money out of pocket from you. 

(Preventive care is covered without cost sharing, meaning your annual wellness visit or a routine cancer screening test won’t cost you money out of pocket.)

But by law, all major medical plans that comply with the ACA must cover these 10 categories of benefits.

Major Medical vs. Short Term Health Insurance

Let’s talk for a second about major medical insurance vs. short term health insurance. 

Major medical plans are required to cover 10 essential health benefits under Obamacare, but not every health insurance plan is a “major medical” one. That’s where things get a little tricky.

Major medical insurance

When we use the term “major medical insurance,” we mean the full benefits required under the Affordable Care Act. You can get a major medical plan from your job (if it offers one) or on your own. These plans may also be called “private” health insurance plans since they’re not from a government program, like Medicare or Medicaid.

Major medical insurance plans are usually ACA-compliant, meaning they adhere to all the requirements of Obamacare. But some major medical plans are considered “grandfathered,” meaning they existed before Obamacare and haven’t changed since then. These aren’t the norm, though.

And if you buy a new health plan through your job, a state or federal marketplace, or a private marketplace like ours, that new major medical plan will likely be ACA-compliant. That means it covers essential health benefits and offers a bevy of consumer protections we won’t get into right now.

Short term health insurance

As the name implies, short term health insurance is health insurance that you buy on a temporary basis. These plans can last from 30 to 364 days, can be renewed for up to 3 years and don’t cover the same types of benefits as major medical policies.

You won’t typically find coverage for things like preventive care, maternity care or — notably  — mental health care. These plans are best for people in transition: college graduates without access to a family plan, new employees waiting on company coverage to start or young adults who just need catastrophic coverage.

Short term plans cost less because they cover much less than a major medical policy. They provide a good safety net for unexpected medical costs, but they are not the same as major medical policies.

Short term health plans don’t have to adhere to ACA rules, including covering essential health benefits. You can be denied based on medical history, and almost no short term plan covers any kind of pre-existing conditions (though you might find exceptions).

Major medical plans can’t deny you based on your medical history, they last a full year and have no caps in place on coverage. Because they cover more and have to follow the ACA’s rules, major medical plans also cost more.

Need the TL;DR version?

Most major medical plans cover mental health care by law. Short term health plans usually don’t have to cover this benefit because they aren’t regulated in the same way. You may or may not find mental health coverage with a short term plan. If you buy a new ACA-compliant major medical policy, that plan will cover mental health care. It has to.

Covered Benefits & Networks

Covered benefits and network limits vary by plan. Since the kind of health plans we’re talking about are sold by private companies, what one plan covers may differ wildly from another in your area.

Still, there are some broad categories within the mental health care benefit that all ACA-compliant plans must cover. These include:

  • Behavioral health treatment, like counseling
  • Treatments for substance use disorders
  • Inpatient services for mental and behavioral health

And while spending limits don’t exist for ACA-compliant major medical plans — Obamacare eliminated caps on coverage for compliant plans — insurers can designate networks. Your health plan may require you to choose from a set pool of providers, for example, or you might pay more for out-of-network care. 

That’s why it’s important to check your health plan carefully when it comes to getting care, for mental health or anything else. The ACA removed a lot of limits for modern health plans, but your insurer can still set some restrictions. Know what your plan will and won’t cover — and to what extent.

Cost Sharing

How much does it cost to see a therapist? And will your health insurance plan cover the full cost? Straightforward questions without straightforward answers — as is usually the case when it comes to insurance costs.

What you pay for covered services depends on your health plan.

Mental health services might require a copay, coinsurance and a deductible. You might have to pay $30 to see a mental health counselor or 30% of the total cost. It just depends on how your health plan handles cost sharing.

And as a reminder, “cost sharing” refers to what you pay out of pocket for your medical care.

Your health plan will lay this information out in black and white in your coverage documents. But if you have specific questions, always call the number on your health insurance card to ask about costs.

Important note: by law, mental health care has to be treated the same as medical coverage in terms of cost and limitations. That’s thanks to a concept called “parity.”

Parity says that if your health plan requires 20% coinsurance for trips to the doctor, that same 20% requirement applies to mental health services. In other words, your health plan can’t raise your cost sharing for mental health services compared to what it offers for covered physical healthcare services. It also has to offer the same plan limits and benefits. 

Most major medical plans sold today have parity.

When and How to Get Covered

You can buy major medical insurance either during open enrollment or a special enrollment period (if you qualify).

Open enrollment happens in the fall. It runs from November 1 through December 15 in all but a handful of states. 

Twelve states and the District of Columbia have their own health insurance exchange sites. These states tend to have a later deadline for open enrollment.

During open enrollment, you can buy a new plan, switch plans or keep your existing one. It’s the only guaranteed time of the year when you can buy major medical insurance if you don’t have a job-based plan or a government program, like Medicaid. (And if you do have a job-based plan or a government one, you’ll follow its rules for enrollment instead.)

Outside of open enrollment, you can only buy major medical insurance if you qualify for a special enrollment period. There are actually quite a few reasons you might qualify for one. They include things like:

  • Losing your job
  • Getting married or divorced
  • Having or adopting a child
  • Moving
  • Getting out of jail
  • Becoming a citizen

Think major life events. If you go through something big during the year and need to change your health plan or get a new one, see if you qualify for a special enrollment period. 

You typically have 60 days from the date of the event to buy insurance. And some situations require physical proof, so make sure to read the requirements carefully when signing up.

As for where to buy health insurance? You’ve got options there, too. 

You can enroll in a major medical plan using or a state-based marketplace if your state has one. Or you could buy it directly from an insurer. Or you could use a private health insurance marketplace, like ours.

Just keep in mind that no matter where you sign up, you’ll still need to wait until open enrollment to buy a major medical plan unless you qualify for a special enrollment period.

Help When You Need It

For some benefits, like hospitalization or ER services, we would normally recommend looking into short term health insurance as a less expensive way to cover unexpected medical crises.

But mental health care is different.

Short term plans don’t usually cover mental health services — counseling, medication, mental hospitals or other related treatments — so we can’t recommend them generally if you need this coverage. You might find a plan that does offer some coverage in this category, but it likely wouldn’t cover pre-existing conditions and wouldn’t be comprehensive like a major medical plan. 

For mental health care and substance use disorders, we recommend major medical plans that comply with the Affordable Care Act.

And if you’re struggling with mental health issues or need someone to talk to but you don’t have health insurance, check out the following list of resources that might help:

Contact one of these organizations or the agencies in the above linked lists for more information and immediate support. Remember: you’re not alone, no matter your health insurance status.