There are different types of health insurance plans designed to meet different needs. A person’s situation will impact the types of insurance that are available. Additionally, the level of coverage someone receives inside and outside of a plan’s network of doctors, hospitals, pharmacies and other medical service providers depends on the type of plan she selects.
Private Health Insurance
Private health insurance includes both individual plans and group plans. Like car insurance, private health insurance requires someone to choose a plan and agree to pay a certain amount each month—known as a premium—in exchange for coverage. Individual plans may be purchased by a single person or a family directly through an insurer or through the Health Insurance Marketplace. Health Insurance Marketplaces, which are run by states, sometimes go by different names.
Who’s Eligible?
Eligibility depends on the type of private insurance. Group plans are usually offered through employers and eligibility requirements may depend on the number of hours worked or length of employment. Some plans offer limited benefits and high deductibles, while other plans may offer broad benefits with low deductibles or co-pays. People can find out if they are eligible for health insurance through a job by asking a supervisor or human resources (HR) department.
A person is eligible for private health insurance through the Marketplace if she:
- Lives in the United States
- Is a U.S. citizen or national (or be lawfully present)
- Is not currently incarcerated
- Can’t get insurance through a job
What Mental Health Benefits Are Covered?
Private health plans vary in their health and mental health benefits, but typically offer fewer mental health services than Medicaid or public mental health programs.
Private plans that are available through a job that cover mental health services typically will cover some level of the following.
- Inpatient hospitalization
- Partial hospitalization
- Outpatient mental health treatment
- Emergency care
- Prescription drugs
Every health plan offered in the Marketplace is required to cover 10 types of services, or “ Essential Health Benefits.” These categories of covered services include:
- Wellness and disease management
- Prescription drugs
- Hospitalization
- Laboratory services
- Emergency services
- Maternity and newborn care
- Children’s care, dental and vision
- Rehabilitation and habilitation
- Mental, behavioral health and substance use care
- Outpatient clinic services
Medicaid
Medicaid is a public state and federal combined health insurance program, which provides health insurance coverage to low-income children and adults who meet certain eligibility criteria. State Medicaid programs may go by different names. Medicaid plans have low costs, but the choice of mental health professionals may be more limited than in private health insurance plans.
Who’s Eligible?
Eligibility for Medicaid varies in every state, but federal law requires states receiving federal funds for Medicaid to cover:
- Pregnant women and children under age 6 with family income below 138% of the federal poverty level (FPL)
- Children ages 6-18 below 100% of FPL
- Parents below state’s July 1996 welfare eligibility level (often below 50% of FPL)
- Most older adults and individuals with disabilities including mental illness who receive federal SSI (generally 75% of FPL)
In most states who have not expanded Medicaid, adults without children are not eligible unless they live with a disability and receive Supplemental Security Income (SSI). If a state has Medicaid Expansion, people can be covered by a version of Medicaid if they earn up to 138% of the FPL.
Benefits for the Medicaid Expansion population vary by state. Medicaid.gov has a list of state Medicaid profiles that details eligibility requirements.
What Mental Health Benefits Are Covered?
Medicaid mental health services vary by state and may vary within a state by plan. Medicaid generally covers:
- Inpatient hospitalization
- Partial hospitalization
- Residential care
- Outpatient mental health services
- Non-emergency transportation
- Case management
- Peer support services
- Psychiatric rehabilitation
- Crisis intervention
- Prescription drugs
- Long-term care
- Early Periodic Screening, Diagnosis and Treatment (EPSDT) services for children
Medicaid plans may cover additional services, including:
- Psychosocial rehabilitative services
- In-home and family support services
- Assertive Community Treatment (ACT)
- Multisystemic Therapy (MST)
By law, Medicaid does not cover state hospital or specialty psychiatric hospital care for people aged 22-64. This is called the Institutes for Mental Disease (IMD) exclusion.
Medicaid.gov has a complete listing of what benefits Medicaid can cover.
Medicare
Medicare is a federal health insurance program that provides coverage similar to private health insurance. Medicare does not cover a broad range of community-based services for people with mental illness.
Who’s Eligible?
- People aged 65 or older
- Adults with disabilities who have received Social Security Disability Insurance benefits (SSDI) for at least 24 months
- People with low incomes (generally 75% of FPL) and limited assets who are enrolled in Medicare may also be eligible for Medicaid coverage (dual eligibles)
- People with end-stage renal disease
What Mental Health Benefits Are Covered?
- Inpatient hospitalization
- Partial hospitalization
- Outpatient services with licensed mental health professionals
- Emergency care
- Prescription drugs under Medicare Part D
Medicare has a 190-day lifetime limit on psychiatric hospital care. If a person qualifies for Medicare, he may also be eligible for additional coverage under Medicaid.
CHIP
Children’s Health Insurance Program (CHIP) is a state and federal combined health insurance program for children in families who earn too much to qualify for Medicaid but not enough to buy private health insurance. CHIP provides free or low-cost health coverage and goes by different names in every state.
Who’s Eligible?
In general a child will qualify for CHIP if he is under age 19 and his family meets certain income requirements. In some states, a family can have a higher income and children may still qualify.
What Mental Health Benefits Are Covered?
CHIP plans with mental health benefits must cover the following services equally if they are covered for other medical conditions:
- Inpatient hospitalization
- Outpatient mental health treatment
- Emergency care
- Prescription drugs
Some CHIP plans may include additional mental health services or the full range of the state Medicaid plan’s mental health services. States are allowed to set premiums and cost sharing on a sliding scale.
TRICARE And VA Health Care
TRICARE and VA Health Care are federally-run health insurance plans for people who have served in the military.
Who’s Eligible?
A person may be eligible for TRICARE if she is a:
- Uniformed Service member or family member
- National Guard/Reserve member or family member
- Survivor
- Former spouse
- Medal of Honor recipient or family member
- Registered in the Defense Enrollment Eligibility Reporting System (DEERS)
A person may be eligible for VA Health Benefits if he:
- Served in the active military service and left under any condition other than dishonorable
- Is a current or former member of the Reserves or National Guard and was called to active duty by a federal order
Learn more about eligibility requirements for TRICARE or the U.S. Department of Veterans Affairs.
If someone served in the military, she may also qualify for enhanced eligibility for VA Health Benefits. Veterans who qualify under this special eligibility do not have to pay copays for conditions potentially related to their combat service.
What Mental Health Benefits Are Covered?
- Inpatient hospitalization
- Partial hospitalization
- Outpatient mental health services
- Psychiatric residential treatment (children and youth)
- Emergency care
- Prescription drugs
Inpatient hospitalization covers up to 30-45 days per admission or year and partial hospitalization covers up to 60 days per year.
VA Health Care provides:
- Inpatient hospitalization.
- Outpatient mental health treatment.
- Residential psychiatric rehabilitation treatment.
- Psychosocial rehabilitation services.
- Intensive case management.
- Emergency care.
- Prescription drugs.
- Supported employment.
However, not all services are available at all locations.
