ACA vs Group Health Plans: Understanding Mental Health Coverage

The Affordable Care Act (ACA) has significantly expanded access to mental health services, but some employer-sponsored group health plans may still have limitations or exclusions. Here’s what you need to know about ACA regulations regarding mental health coverage and how to address potential issues.

Mental Health Coverage Under the ACA

The ACA prohibits group health plans, including employer-sponsored plans, from imposing lifetime or annual limits on mental health benefits. Plans must provide coverage for mental health services that are medically necessary. This includes:

Inpatient psychiatric care
Outpatient mental health care
Mental health medications
Substance abuse treatment

Grandfathered Plans

Some group health plans may be “grandfathered” under the ACA. These plans existed before the ACA and were allowed to keep some pre-ACA rules. Grandfathered plans may have lower mental health coverage than ACA-compliant plans, but they cannot impose lifetime or annual limits.

Employer Penalty

Large employers (generally those with 50 or more employees) face a penalty if they do not offer health insurance coverage that meets the ACA’s minimum essential health benefits. These benefits include mental health coverage. Employers may choose to pay the penalty instead of offering compliant coverage.

Addressing Coverage Issues

If your employer’s group health plan has an exclusion for mental health treatment, you should take the following steps:

1. Check if your plan is grandfathered: Contact your employer or health insurance provider to determine if the plan is grandfathered.
2. Contact your employer: Discuss your concerns with your employer. Explain the ACA’s requirements and ask if they can modify the plan to comply.
3. File a complaint: If your employer does not take action, you can file a complaint with the U.S. Department of Health and Human Services (HHS).

Getting Help

If you have difficulties accessing mental health services through your group health plan, you can also seek assistance from:

Licensed health insurance agents: They can provide guidance on understanding your coverage and identify other options for mental health care.
Mental health providers: They can advocate for your needs and provide information on obtaining affordable mental health services.
Community health centers: They often offer mental health services on a sliding scale based on income.

Remember, you have the right to access necessary mental health care. By understanding the ACA’s regulations and taking the appropriate steps, you can ensure that your mental health needs are met.