Understanding Your Mental Health Care Insurance Coverage and Care Options

When you have health insurance and crash while in-line skating, the next steps on getting that (hopefully) sprained wrist checked out are pretty straightforward.

People who face mental health problems, be it anxiety, depression or PTSD, however, might not know how – or if – their health coverage works for these challenges. More than one in five American adults faces a mental health condition each year.

“Health, be it physical or mental, is health,” said Avera Health Plans Chief Medical Officer Preston Renshaw, MD.

Before 2014 and the Affordable Care Act (ACA), not all health insurance plans covered mental health services. Or having mental health coverage may have required an expensive rider. Now, mental health services are an essential benefit of ACA-approved plans.

How Your Health Insurance Coverage Works for Mental Health

If you have health insurance coverage in place, review all information, that explains your plan and its offerings. You can find information about specific plans in your Summary of Benefits and Coverage by logging into your member portal. Many preventive measures, such as a yearly checkup/annual wellness exam, will include screening for common mental health considerations.

"If you have health insurance, almost any mental health situation, from going to an emergency room to outpatient treatment for substance abuse, is covered under ACA guidelines,” said Renshaw. "Patients should remember that ongoing steps in your care journey may include out-of-pocket costs,”

Consider Out-of-Pocket Costs for Mental Health Care

Costs will come in three main forms: your deductible, co-pays and coinsurance. Also be aware of the out-of-pocket maximum for your plan.

You will have out-of-pocket costs toward your deductible and co-insurance until you meet your out-of-pocket maximum for the year. Then, your expenses are covered at 100%.

Your plan type is also something to be aware of. Plans with higher monthly premiums typically have lower deductibles. A high-deductible plan typically has a lower monthly premium. If you have a high-deductible plan, you are responsible for that first dollar up to the total of the deductible.

Coverage for Clinic Visits and Inpatient Care

Your yearly checkup with your primary care provider is covered at 100%. If you are having mental health symptoms, this is the perfect time to bring it up. Your provider may offer you a mental health screening tool as part of the visit. Your provider might refer you to counseling or a psychiatrist, or prescribe medications that can help.

If you see a counselor or therapist that’s within your network of providers, it’s treated like a provider visit for which you would likely pay a co-pay.

If you need care such as inpatient hospitalization, partial hospitalization or residential addiction care, these are subject to deductible and co-insurance.

Medication for Mental Health and How It’s Covered

Many people who face a behavioral health challenge can use medication for relief. Like health insurance coverage for physical injuries and conditions, medication is usually part of your plan.

“There can be exceptions, but most often, your clinician can help you find meds that help and that are covered," Renshaw said.

Additional Benefits and Programs that Can Help

Many coverage plans include programs that look at health risk assessments and provide members with coaching, answers and other aspects of care that can assist you. For example, health coaches or assessors could refer members who respond to risk questions that indicate they face depression or anxiety, and then guide them in the decisions they might face with their coverage.

“Use the offerings you have on your health insurance plan to help you overcome mental health challenges – it’s vital,” said Renshaw. “Conditions like anxiety and depression are very prevalent and getting worse for our population as a whole.”

Virtual Visits for Behavioral Health

Avera Health Plans members can get mental health care from the comfort and privacy of home with virtual visits. Licensed therapists and board-certified psychiatrists are available for weekday, weekend and evening appointments to help address mental health concerns like these:

• Anxiety
• Panic attacks
• Depression
• PTSD/trauma
• Insomnia
• Social anxiety
• Life transitions
• Stress management
• Obsessive-compulsive disorder

Through virtual visits, therapists offer tools for stress management and coping with feelings. Psychiatrists can help manage mental health conditions with ongoing medication management. Those who wish to continue seeing their current Avera behavioral health provider are not able to complete their visits via these virtual visits. Members can download the Avera Health Plan Virtual Visits app from the App Store or Google Play to get started.

Employee Assistance Program

Your employer might offer an Employee Assistance Program (EAP). These programs offer free confidential counseling sessions to employees and their dependents. “If you go to additional EAP sessions, these are almost always covered by your insurance. But often EAP free sessions and covered sessions go unused,” Renshaw added. Avera’s EAP program offers virtual sessions.

Help if You Don’t Have Health Insurance

“If you don’t have coverage, unfortunately, a new diagnosis of a mental health condition does not allow you to qualify for signing up,” Renshaw said.

If your condition is ongoing, consider purchasing coverage next time open enrollment rolls around, either through your employee health plan or individual and family plans through the federal Marketplace. That way, you have coverage into the next year. “If you have an experience with mental health difficulties, and you can join an insurance group, make a note to know when open enrollment starts – it can make a huge difference,” Renshaw added.

Other opportunities exist for individuals and families to find help when facing mental health challenges such as:

• Sliding-scale provider services or charity care services if you are unable to pay for health care expenses
• Low-cost community mental health clinics
• Support groups or group therapy programs
• Programs designed to help employees with issues
• Behavioral health programs offered at colleges and universities
• Toll-free hotlines, such as 988 Suicide and Crisis Lifeline

“There are offerings that can help, including those online,” Renshaw said. “Efforts within the Affordable Care Act have made more programs available.”

Learn More

Connect to services at Avera Behavioral Health

Read more about mental health well-being