Not too long ago, medical insurance plans didn’t have to cover treatment for mental health and substance use disorders (SUDs). But now, with the introduction of the Affordable Care Act, mental and behavioral health services are now considered essential health benefits. All plans must cover:
- Treatment for behavioral health such as psychotherapy and counseling.
- Mental and behavioral health inpatient treatment.
- Substance use disorder (formerly known as substance abuse) treatment.
The particular behavioral health benefits you receive will depend on your state and the health plan you choose. Your personal choice of health insurance carrier will depend upon:
- The kind of health insurance you need
- Your budget
- Where you live
The Humana Story
Humana has about 14 million members and ranks No.4 for U.S. health insurance companies. In addition, Humana is ranked 1st for all health insurance companies for social responsibility in a recent survey in Forbes magazine. At present, Humana Inc is a Fortune 500 company based in Kentucky and one of the largest health insurers in the country.
Humana started in the 1960s as a nursing home operator and grew to be the largest in the nation. Thirty years later, the company changed its name and was the largest hospital operator in the country and had even created its own health insurance plans. Eventually, Humana decided to let go of the hospital division and focus on healthcare plans.
The Affordable Care Act and Mental Health and SUD Benefits
As of 2014, most small group and individual health insurance plans are required to cover mental health and substance use disorder services. Likewise, Medicaid Alternative Benefit Plans also must cover mental health and SUD services. Under the health care law, these plans must have coverage of essential health benefits, which include 10 categories of benefits. Among those categories are:
- Mental health services
- Substance use disorder services
- Rehabilitative and habilitative services
Also, the plans must fulfill the health and substance use parity requirements as stated in the MHPAEA (Mental Health Parity and Addiction Equity Act). This means that coverage for mental health and substance abuse services has to be equal to or greater than the coverage for medical and surgical services.
Basic Insurance Terms
Before discussing plans, let’s go over some of the terms. It’s important to know what you’re buying or what you already have. Common terms are:
- Premium—This is the amount you pay each month for insurance.
- Deductible—Some plans have a deductible. The amount you pay before your plan pays 100% of the cost.
- Copay—Copay is a flat fee that you pay when you receive services.
- Coinsurance—Coinsurance is when you pay a percentage of the charges for care.
- In-network and out-of-network—Insurance plans have providers who accept their insurance in their “network.” Going to a provider who is not in your insurance company’s network may not be covered or only covered in part.
What Are Different Levels of Coverage?
When you shop for health insurance, you have choices of plans. Whether you’re buying from your state’s Marketplace or an insurance broker, you will choose from plans that are organized by the benefits they offer: bronze, silver, gold, or platinum.
Bronze plans have the least coverage and platinum plans have the most. You may be able to buy a high-deductible, catastrophic plan if you’re under 30. There are many insurance brands associated with the care levels including large national brands like Humana.
What makes them different?
Each plan pays a set share of costs for the average enrolled member. The details can vary according to the plans. Also, deductibles—the amount you pay before your plan pays 100% of your costs—will also vary according to plan. Usually, the least expensive has the highest deductible.
Platinum plan: The platinum plan covers an average of 90% of your medical costs and you pay 10%.
Gold plan: Gold covers an average of 80% of your medical costs and you pay 20%.
Silver plan: Covers an average of 70% of your costs and you pay 30%.
Bronze plan: This covers 60% on average and you pay 40%.
Catastrophic: Catastrophic policies pay after you have reached a high deductible amount ($8,150 in 2020). They also cover your first 3 primary care visits and preventive care for free.
What are the Types of Plans?
Each brand of insurance may offer one or more of these four types of plans.
Health Maintenance Organizations (HMOs)
- Little freedom to choose health care providers. All services are through a network of healthcare providers and facilities.
- Your primary care doctor will manage your care and refer you to specialists if needed.
- If you go to a doctor who is not in the network, you will pay the full bill yourself. Emergencies at out-of-network hospitals are covered at in-network rates and you pay the balance.
Preferred Provider Organizations (PPOs)
- You have some freedom to choose your healthcare provider. You don’t have to get a referral to see a specialist.
- Higher costs if you see an out-of-network doctor.
- If you have a deductible, you will probably pay a higher deductible for seeing an out-of-network doctor.
Exclusive Provider Organizations (EPOs)
- You have some freedom to choose your health care provider and you don’t have to get a referral to see a specialist.
- You will have no coverage if you see a provider that’s not in your plan’s network, except in an emergency.
- Lower premium than a PPO
Point-Of-Service plans (POS)
- Some freedom to choose your health care providers. You can see out-of-network doctors but you will pay more.
- Your primary care doctor manages your care and refers you to specialists.
- You can go to any doctors in the plan network.
- Individual plans may have rules about seeing specialists.
- 3 primary care visits before the deductible applies.
- Free preventive care, whether you have met the deductible or not.
High-deductible health plans (HDHPs) Sometimes Linked to Health Savings Accounts (HSAs)
- You may have an HMO, PPO, EPO, or POS.
- Higher personal costs than other types of plans. If you reach the maximum out-of-pocket amount, the plan pays 100%.
- An HSA to help pay for your care. This is money you put in a health savings account which is not taxed and can be used tax-free on eligible medical expenses. To have an HSA, you must be enrolled in an HDHP.
- Bronze plans may qualify as HDHPs depending on the deductible.
- Generally has lower premiums.
- Preventive care is free regardless of meeting the deductible.
- You can set up a Health Savings Account to help pay for your costs.
Using Insurance for Mental Health and SUD Care
Most small group and individual health care plans are required to cover mental health and substance abuse treatment. But using health insurance can bee seen differently when dealing with care for your body versus care for your mind. There are some factors that should be considered when deciding the best options for paying for mental health care.
Reduced Costs for Prescribed Medicine
For people diagnosed with a mental illness or SUD and are prescribed a medication, medical insurance can often reduce the cost of medication substantially. If you are seeing a therapist for talk therapy and paying on your own, many insurance companies will still cover your medications
Impact of Pre-existing Conditions
Under the current Affordable Care Act currently, all Marketplace plans and most other insurance providers must cover behavioral health treatment such as psychotherapy and counseling. This includes substance use disorders and other behavioral health services. They can not deny or charge more for pre-existing medically diagnosed mental health conditions, regardless of the reason you are seeking care.
You need to be aware of changes in legislation and caps on the number of visits. Healthcare is a constantly changing field. Some insurances limit the number of visits. Some allow a full year while some limit it to 10 visits. Others may require you and your therapist to file for allowances to extend the limits.
Finding a Therapist that Accepts Insurance
Most people don’t realize that many mental health professionals don’t accept insurance. A reason for this is because of the poor relationship between therapists and insurance companies. The poor relationship is because insurance companies cause therapists to make significantly less money or be responsible for large amounts of paperwork they aren’t compensated for.
All of this can cause extensive wait times for patients. Going through an insurance company to see a therapist can have a wait time of up to four months. This is just not practical for someone with a mental condition.
Your treatment must be deemed medically necessary to be covered. This is a standard used by insurance companies to determine if the treatment recommended by your health care provider is reasonable, necessary, and appropriate. If it meets those standards, then it will be covered.
Treatment Options for Substance Use Disorder
Deciding to get help and treatment for an SUD is the first step to getting better. Humana has some plans with behavioral health benefits that may include coverage for the treatment of substance use disorders.
Treatment may focus on:
- Intensive and early intervention
- Individualized care that concentrates on the whole person, body, and mind. If you have a substance use disorder, you may have a co-occurring mental health disorder too. It doesn’t matter which came first, they must be treated together. This is called a dual diagnosis.
- Efforts to remove the stigma tied to having a substance use disorder
Treatment options include:
- Medication-assisted treatment
- Peer groups
- 12-step groups
- Inpatient treatment
- Outpatient treatment
Discovery Institute for Mental Health and SUDs
Making the decision to get help for an addiction or mental health condition is a daunting undertaking. But the Discovery Institute is available to answer your questions 24 hours a day. Maybe it’s someone close to you who is in need of help. Decide to help your loved one now. Contact us here.
We have a staff of medical professionals and licensed therapists whose only job is to help you achieve your best outcome. This won’t get better on its own and you know that. Get the care that you need and deserve.