Obamacare and Mental Health

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Obamacare and Mental Health


Healthcare changed for millions of Americans. The Affordable Care Act (ACA) was passed allowing millions of Americans with pre existing conditions the chance to finally get health care coverage. The Affordable Care Act made several changes to the tax code with the intention to increase health insurance coverage, reduce the cost of healthcare, and finance health care reform.

Prior to 2010 insurance companies were able to decline individuals based on their health. People were declined coverage for serious, expensive , life threatening conditions like cancer and heart disease. People were also turned down for coverage on pre-existing conditions like high blood pressure, which affects 75 million Americans and diabetes which affects 100 million Americans. Mental health, pregnancy, obesity or history of drug abuse were also a “no-go”. The only way to get insurance with any type of pre existing condition was basically through employment and even then there were penalties and point systems insurance companies used to “limit their risk”.

So what did the affordable care act do, exactly?

1) Obamacare created a “marketplace” there a person can view coverage and compare plans easily.

2) Consumers can not be declined coverage for a pre existing condition. Insurance carriers must extend coverage to everyone.

3) Health insurance plans are subsidised to make them affordable, this is based off of a person’s income.

All plans in the Marketplace cover at least the same set of essential health benefits.Generally, plans in categories with lower premiums pay less of your total costs and categories with higher premiums usually pay more of one’s total out of pocket costs.

Every health plan MUST cover the following services.

Ambulatory patient services (outpatient care you get without being admitted to a hospital)

Emergency services

Hospitalization (like surgery and overnight stays)

Pregnancy, Maternity, and newborn care (both before and after birth)

Mental health and substance abuse disorder services must be covered,including behavioral health treatment (this includes counseling and psychotherapy)

Prescription drugs

Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills)

Laboratory services

Preventative and wellness services and chronic disease management

Pediatric services, including oral and vision care ( adult dental and vision coverage are not part of the essential health benefits)

Now although all these essential health benefits are required to be covered the actual coverage varies plan to plan. Depending on household income a “premium tax creditcould be applied which will lower the cost of one’s health care plan.

Mental and behavioral health services are covered under essential health benefits through Obamacare. All plans must cover:

  • Behavioral health treatment, such as psychotherapy and counseling
  • Mental and behavioral health inpatient services
  • Substance use disorder (commonly known as substance abuse) treatment

Your specific behavioral health benefits will depend on your state and the health plan you choose. You’ll see a full list of what each plan covers, including behavioral health benefits, when you compare plans in the Marketplace.

What does this mean if you or a loved one has the pre existing condition of mental health and/or substance abuse disorders? Insurance providers like aetna, blue cross blue shield, cigna, United health care cannot reject you. No insurance plan can reject you, charge you more, or refuse to pay for treatment of mental health and substance abuse conditions. This includes substance abuse and mental health conditions existing before coverage begins.

Once a person is enrolled, the plan cannot deny coverage or raise rates based solely on personal health. It’s important to look at each plan individually to make sure you’re buying a health plan that is going to cover your health and wellness needs. Keep in mind deductibles and out of pocket expenses that the policyholder is responsible for.

Parity Protections for Mental Health Services

This was a huge deal in 2010 and a big step forward for advocates of mental and behavioral health rehabilitation. Parity protection for substance abuse and mental health means that those illnesses must be covered the same way This generally means limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services. The limits covered by parity protections include:

For years prior to obamacare or ACA policy holders suffering from substance abuse were only allowed limited treatment attempts in a year. For example if a person with a substance use disorder went to treatment for heroin addiction once and released the insurance carrier would deny paying for further treatment. Parity Protections for mental health services Marketplace plans must provide certain “parity” protections between mental health and substance abuse benefits on the one hand, and medical and surgical benefits on the other.

This generally means limits applied to mental health and substance abuse services can’t be more restrictive than limits applied to medical and surgical services.

  • Financial — like deductibles, copayments, coinsurance, and out-of-pocket limits
  • Treatment — like limits to the number of days or visits covered
  • Care management — like being required to get authorization of treatment before getting it.

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