Each year, an estimated one in four U.S. adults deals with a mental health issue, and at last count, close to 22 million people met the criteria for a substance use disorder. That’s the bad news.
The good news is that fewer of us have to go it alone when facing such problems thanks to the combined effects of two pieces of legislation: a 2008 parity law that requires insurers that offer mental health and addiction treatment coverage to provide it at the same levels as medical care, and the Affordable Care Act (ACA), which established access to individual and small group insurance plans that make mental health and addiction treatment an essential benefit. In fact, by 2020, an estimated “62 million people will either gain new coverage or get covered by health coverage that includes parity protections that weren’t there before,” explained David DeVoursney, branch chief of the Office of Policy Planning and Innovation for the Substance Abuse and Mental Health Services Administration.
Still, despite the broadened coverage, it’s far from smooth sailing. Some have struggled with pushback from insurance companies reluctant to live up to the full letter of the laws. Others with coverage for the first time aren’t sure how to use the help at their disposal. Still others aren’t even aware that they are legally eligible for such coverage. If mental health and addiction treatment benefits matter to you — and for your well-being, they should — these tips can help you make the most of them.
Know what you have.
Your insurer is required to provide you with an easy-to-understand explanation of your benefits, so if you’re not sure how extensive your mental health and addiction treatment coverage is or if you even have any, ask. Insurance offerings vary and some plans remain exempt from the new provisions, but in the majority of cases today, DeVoursney explained, if you have a health plan, you also have mental health and addiction treatment benefits with the parity protections.
That means, for example, that if your health plan charges no co-pay for medical services, it should also demand no co-pay for mental health services. “The crux of the parity protections is that generally there shouldn’t be restrictions on mental health and substance use benefits that aren’t also applied to physical health benefits,” DeVoursney said.
Striking that balance is not always so clear-cut, however, and it can become tricky to determine just what constitutes parity in some areas. That makes it even more important to know what’s in your health plan so you can be your own advocate. “Don’t just assume that because you are challenged by your insurer on something that you don’t have the protections,” DeVoursney said.
Shopping for health plans during open enrollment — whether mulling the offerings of an employer or comparing the individual policies available — is complicated business, but doing your homework pays off, DeVoursney said. If you know you’ll need a certain type of mental health or addiction treatment service, for example, make sure the plan you are considering covers it before you sign up. “And look at the level of copayments or coinsurance,” he said. “If you’re living paycheck to paycheck and you have coverage for counseling in your plan but are required to pay a $30 copay every time you go in, that may be cost prohibitive.”
Anyone can seek coverage through the insurance marketplace set up by the Affordable Care Act, DeVoursney noted. Just keep in mind that if you have access to health insurance through your employer and forgo it to buy an individual plan through the marketplace, you won’t be eligible for the subsidies that generally make such plans affordable.
For information on plans and to be connected to your state marketplace, as well as to locate insurance navigators and assisters who can help you make a decision about what coverage is best for you, visit healthcare.gov.
Once established with a heath plan, DeVoursney emphasized, “pay attention to what’s in the plan summary documents and the materials you receive, and be sure that you are receiving those benefits.” If you find you need more information, request it. Your insurer is required by law to provide it.
Fight for your rights.
If you feel you aren’t getting all that you are entitled to from your mental health and substance use disorder benefits, there are places to turn for help.
A good first step, DeVoursney said, is to take your grievance to your state insurance commissioner. You can get contact information for your area through the State Association of Insurance Commissioners.
If that doesn’t lead to a solution, you have other options, depending on where your plan originated. If you are covered through an employer, contact the Department of Labor and speak to a benefits adviser toll free at 866-444-3272 or submit an online request for assistance. If you have an individual plan, one bought through the health insurance marketplace or a Medicaid plan, request help through the Centers for Medicare and Medicaid Services at cms.gov by emailing email@example.com or calling 877-267-2323, extension 61565.
Stories of insurers dragging their feet on mental health and addiction treatment coverage are, sadly, not uncommon, so be prepared to be assertive.
If you need your benefits, use them.
We all hope, of course, that we’ll never have to use the mental health and substance use disorder treatment benefits now available to so many of us. But we shouldn’t shy away from taking advantage of them. The sooner you act, the more likely it is that emerging problems won’t become big ones. Don’t wait until your depression or anxiety is so bad that you can’t get out of bed or your drinking has cost you your job before reaching out for help, for example. You can even be proactive and schedule a mental wellness visit, just as you might schedule an annual physical with a doctor.
Remember, those benefits aren’t just something to be dipped into when you’re at the end of your rope; they’re about keeping you from getting there.
National Alliance on Mental Illness: Mental Illness Facts and Numbers
Behavioral Health Trends in the United States
Affordable Care Act Expands Mental Health and Substance Use Disorder Benefits and Federal Parity Protections for 62 Million Americans