Mental Health & Insurance Coverage
By Michael Giusti
Mental health care is an essential component of staying safe and healthy, which is why it is supposed to be treated exactly like all other health care by insurers and providers. And yet, millions of people in the nation go without the mental health care that they need — either because they don’t understand the coverage options available to them, because they are succumbing to old stigmas and stereotypes, or because there just aren’t sufficient mental health providers to go around.
Finding care begins with an understanding of what is covered, how it is covered, and of the real limitations that must be overcome.
But with some knowledge and due diligence, mental health coverage should be just as accessible as any other health care service.
What is Covered by Insurance for Mental Health Care?
Federal law dictates that Affordable Care Act compliant health insurance plans must cover mental health care with “parity” compared with other types of essential health care. That means that the costs and coverages should be the same for a therapist visit as it is for a physician’s visit. Pre-existing conditions are also covered, and coverage is supposed to begin the day coverage starts.
So, if a chronic condition, such as diabetes is allowed unlimited doctor’s visits by a plan, that plan would also need to offer unlimited visits for depression, for example.
That includes psychotherapy and counseling; mental and behavioral inpatient services; substances use disorder treatments; inpatient services; and prescription medications.
Specific details of copays and coverages do differ by state and by individual plan, but the overarching rule remains that mental health, by law, must be treated the same as all other health care.
Coverage doesn’t stop at private health plans, either.
Medicaid is the largest single payer for mental health services in the country. Mental health coverage is also mandated for recipients of the state-run Children’s Health Insurance Programs. In addition to the typical mental health benefits, children on CHIP plans also qualify for a wide range of screenings under the Early and Periodic Screening, Diagnostic and Treatment program.
Medicare Part B also offers mental health resources, including one depression screening per year, psychotherapy, substance use treatment, and counseling.
Even still, according to KFF, 27% of adults still have unmet mental healthcare needs, illustrating that there are gaps between what should be covered and the care that is being delivered.
Limits to Mental Health Care
Just because a health plan grants coverage for a service, that doesn’t mean that a provider — or the right provider for that matter — is available for every patient.
According to the National Alliance on Mental Illness, more than one-third of all patients reported that they struggled to find mental health providers who were covered under their insurance plans.
In many areas, and specifically in rural communities, there just aren’t enough mental health providers to go around.
According to the American Association of Medical Colleges, more than 150 million people live in an area declared by the federal government as a “mental health professional shortage area.” By their count, the country is short of between 14,000 and 31,000 mental health professionals to properly meet the nation’s demand.
On top of the nationwide lack of providers, many patients allow stigmas and long-held prejudices surrounding mental health get in the way of them seeking care. According to one study published in the National Institutes of Health, social stigma surrounding mental health continues to be a barrier for people who might otherwise seek treatment.
Mental Health Statistics & Coverage
Nationwide, uninsured patients were the least likely to receive care, according to a study by KFF. Medicare and Medicaid recipients were the most likely to receive care, followed closely behind by patients with employer-sponsored plans.
One outlier group was patients with non-group insurance. Non-group policyholders were better off than uninsured, but lagged behind the other groups, with only 55% of patients seeking the help that they needed. That was attributed to the thin provider networks many non-group policies offer.
Women were more likely than men to receive care for their mental health, with 65% saying they received treatment, compared with 53% of men.
White patients reported the highest rate of mental health care usage, with 64% of white people indicating they received the mental health care they needed, compared with 60% of Hispanic people and just 47% of Black people.
Overall, 61% of adults reported that they pursued the mental health care they needed, but young adults aged 18 to 26 reported the lowest usage rates, saying only 45% received the care they needed.
That gap in coverage shows a special vulnerability that emerges among patients between the time they transition from pediatric care to adult care. That gap shows a unique vulnerability of patients to fall through the cracks, where they may have previously been receiving care as a child, transitioning that care into adulthood wasn’t always smooth.
Finding the Right Mental Health Help
Beyond a general lack of providers, a common refrain heard from people pursuing mental health care is the lack of information available to differentiate one provider from the next.
A patient can visit their insurer’s provider list on their website and get a list of covered providers, but that is typically where that referral resource ends. Often the insurer’s search tools are limited by geography, degree, and race/gender. Things like coverage specialty, or more nuanced questions of therapy approach often aren’t accounted for.
With only a general list of names, patients often feel like they are making a highly personal choice simply by picking a name out of a hat.
And too often, that pool of names is lacking in diversity.
According to a study published in Psychiatry Online, while the racial and ethnic makeup of mental health providers has been growing through the years, the demographic makeup of the profession still is far from reflective of the overall demographics of society at large, meaning people from underrepresented groups or minority races or ethnicities still struggle to find providers of a similar background, much less ones who specialize in their unique needs.
A study published in the Journal of the American Pharmacists Association points out that cultural competency by a mental health provider allows patients to feel comfortable and makes them more likely to seek out care.
Finding mental health providers who are a match with similar backgrounds, beliefs, or who speak a common language continues to be a struggle for the industry.
Solutions for Mental Health Delivery
One bright spot in mental health delivery is the increased prevalence of mental health screenings that are being completed routinely by primary care physicians. The theory is that even if someone might be reluctant to initially seek out mental health care, with a trusted primary care physician initiating the conversation, it might make the patient more open to pursuing more formal care.
When it comes to the geographic and demographic limitations of the mental health work force, technology seems to be filling the gaps, at least in part.
One offshoot of the COVID-19 pandemic was the push to move many aspects of the health care system into a virtual environment. And even as other aspects of the industry have long moved back to an in-person delivery model, telehealth services have continued to grow in the mental health space.
Telehealth services allow rural patients to access providers who might be hundreds of miles away. They also allow minority and underrepresented groups to find providers who specialize in their area of care, but who might be located in another area of the country.
When it comes to prescription medications, the federal government relaxed telehealth prescribing restrictions during the pandemic. That led to an explosion of prescribers issuing prescriptions, even without having ever met their patients in person.
Critics said that led to many unnecessary prescriptions, especially in the area of attention deficit, hyperactivity disorder medications and other areas, such as anti-anxiety medications.
In some cases, ADHD medications faced supply disruptions due to excess demand.
Other critics were concerned the prescription of the opioid medication buprenorphine would be abused in a virtual prescription environment.
Despite the critics, many mental health providers have said the flexibility and extension of their reach through telehealth outweighs many of those concerns. For their part, Health and Human Services has extended the telemedicine prescription flexibilities for most patients through November, and for existing patients who have seen their provider at least one time in person until November of 2024.
A role for AI
The fact remains that there are tens of thousands of fewer mental health providers available than would be required if everyone who needed mental health care were to pursue it.
Some advocates and researchers are envisioning that artificial intelligence may pose some solutions.
Large language models, such as OpenAI’s GPT4 may play a role in the future as a therapy chat bot.
Advocates point out that artificial intelligence is a scalable solution that would is available 24/7.
Patients could conceivably log in and receive their psychotherapy whenever and wherever they felt the need, leading to a more accessible care model than was ever before conceived of.
The hope is that through scale, AI therapists could help bring down the cost of care.
And theoretically, therapy through an AI chat bot could be private and anonymous.
The speed and processing power of AI could also help potentially diagnose patterns and problems in ways a human therapist might otherwise miss.
But on the other side of the ledger, critics contend that an AI therapist will suffer from a lack of human connection and a limited emotional understanding.
They also say that while the chat could potentially be private, it would be equally easy for a less scrupulous provider to collect personal data, presenting potential privacy concerns.
And while it is romantic to imagine an all-knowing AI seeing every possible symptom and coming up with instant solutions, a lack of insight, intuition, and experience an experienced human therapist might bring to the relationship could easily result in potential diagnostic limitations for the AI competition.
On yet another hand, the lack of human connection might actually be a positive aspect for some patients.
Say, for instance, in cases where social stigma or limitations may make it hard for someone to talk to a human about their problems, or if the patient were on the autism spectrum and have trouble with face-to-face conversations, chatting with an AI might actually make therapy more accessible.
Some studies with veterans suffering with post-traumatic stress disorder bare this theory out to a degree.
Another potential use for AI in mental health would be to integrate AI into other apps on devices such as a laptop or a smartphone to examine the user’s day-to-day behavior. By watching daily patterns, the AI could help diagnose changes in behavior, which could possibly suggest mental health issues developing.
For example, if someone’s typing patterns changed, or the frequency or length of a phone call changed, those could be hints that there are changes that should be checked out by a therapist.
But that has the downside both of potentially many false positives, as well as the loss of privacy many people may bristle at by having a judgmental AI bot looking over their shoulder as they go about their daily lives.
The road ahead
The best bet for someone seeking to establish a relationship with a mental health provider is often a multi-step approach, beginning by asking a loved one or trusted friend for a recommendation, followed by seeing who is covered in network by their insurer.
The National Alliance on Mental Illness offers several tips for finding a mental health provider that fits the patient’s needs.
Those tips range from checking the demographics of the provider to the type of license the provider has, languages spoken, and even what area of specialty the provider offers, if that information is readily available.
In cases where options are thin, telehealth has opened up a lot of options, even if not everyone is comfortable with limiting their therapist relationship to a virtual chat.
Despite some significant challenges facing people pursing mental health care, insurance coverage should not be one of them. With the federal parity rules, as long as a mental health provider is available in network, that care should be covered in the same way any other essential health care service is covered.
Michael Giusti, MBA, is senior writer and analyst for InsuranceQuotes.com
