Mental health care and the Marketplace: what you need to know

More recently, mental wellness and options for care have come to the forefront of larger conversations around health in America. Thanks to the Affordable Care Act (ACA), coverage for mental health has expanded extensively, with abundant opportunities for care now available to individuals and families.

With so many options for plans, researching and selecting effective and affordable coverage can seem daunting  — especially when bringing different kinds of mental and behavioral health services and providers into consideration!

HealthSherpa has put together this quick primer to help you get up to speed on the basics of mental health coverage included in Marketplace insurance. Read on to learn what’s included, for how much, and how to ensure you and your loved ones are covered and getting the well-rounded care you deserve.

First, a few helpful key terms…

  • Mental health: our emotional, psychological, and social well-being.
  • Behavioral health: a slightly broader categorization. According to USF, “behavioral health involves analyzing and understanding how human behavior is influenced by social, physical and mental factors and how human behavior, in turn, impacts physical well-being, empowerment, and engagement in all aspects of care.”
  • Substance use disorder: substance use or dependence. Mental health issues and substance use disorders sometimes occur together.

Is mental and behavioral health care included in all Marketplace health insurance plans?

They are! The ACA mandates that mental health services are included under “essential health benefits”. Essential health benefits, such as hospitalization and prescription medication, must be covered by all plans in the insurance Marketplace. Furthermore, all Marketplace plans must include the following care options for mental and behavioral health, as well as substance use disorder:

  • Behavioral health treatment, including psychotherapy and counseling. These are options for treatment of mental illness by a professional such as a psychologist or licensed therapist.
  • Inpatient services for mental and behavioral health.
  • Treatment for substance use disorder, commonly referred to as substance abuse.
  • Rehabilitative and habilitative support services for people with behavioral health challenges.

How do I know which services are included in my Marketplace plan?

As with primary care, specific mental health benefits depend on your state of residence and your health insurance provider. Fortunately, the ACA requires insurance companies to provide clear summaries of benefits, including those for mental health care. Your benefit summary includes a breakdown for in- and out-of-network costs related to mental and behavioral health and substance use disorder.

Are there preventive services included in Marketplace mental health care?

Yes! The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) helps ensure most plans include preventive mental health services such as:

  • Depression screening. Depression is one of the most common mental illness diagnoses, and screening for it is a helpful step towards treatment and wellness.
  • Behavioral assessments for children. These assessments identify causes for children’s behavioral issues, such as developmental delays and attention-deficit disorders. Diagnoses help inform treatment plans and education programs.

These services are at no additional cost when included in your plan. Again, your benefit summary denotes which preventive mental health and substance use disorder services are included.

Can I be denied mental health coverage because of my pre-existing condition?

No. Plans on the Marketplace cannot deny you coverage based on a pre-existing condition. They also cannot charge you more because of mental or behavioral health issues or substance use disorder.

Are any of these mental health services free or subsidized?

Many plans fully cover preventive services, like the depression screening and behavioral assessments mentioned above. Additionally, individuals at or below the federal poverty level can qualify for cost-reductions.

An important note: Marketplace plans cannot put dollar limits on coverage for mental health and substance use disorder services (or on any essential health benefit, for that matter). The MHPAEA makes sure of that, as well as mental health and substance abuse parity. This means coverage for these areas cannot be more restrictive in cost than coverage for traditional medical services like primary care or surgery.

To clarify, say you pay a $25 copay for a standard visit to your primary care doctors. The MHPAEA ensures your insurance company charges a comparable copay for a visit to your mental health professional, such as a psychologist.

How do I enroll?

It’s the Open Enrollment Period for 2018! Refer to our simple guide for buying Marketplace health insurance in your state. Be sure to review each plan’s benefit summary for a breakdown of covered mental and behavioral health care services.

Have lingering questions? Reach out to the HealthSherpa team or refer to any of the helpful resources listed at


HealthSherpa is a free website and team of real people who can help you find, enroll in, and make the best use of your marketplace health insurance.

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